Sustainable care for children with cancer: a Lancet Oncology Commission

Burden of prolonged treatment delay among patients with common cancers in the Philippines

PURPOSE

Prolonged treatment delay often leads to adverse cancer prognosis. However, the demographic and clinical predictors of higher treatment delay burden in the Philippines have not been thoroughly evaluated.

METHODS

We conducted a population-based retrospective cohort study on patients diagnosed with common cancers who received cancer treatment, to quantify the burden of prolonged treatment delay in the Philippines among this population. We analyzed 20,654 patients with common cancers from the Department of Health-Rizal Cancer Registry. The Poisson regression model with robust variance was used to identify demographic and clinical predictors of prolonged treatment delay. In addition, we examined the associations among those receiving different initial treatment types, including surgery, radiotherapy, and chemotherapy.

RESULTS

We found 35.1 % of the studied cancer patients experienced initial treatment delay of more than 30 days, as well as 25.2 % and 20.0 % experiencing treatment delays exceeding 60 and 90 days, respectively. We found higher risk of prolonged treatment delay of more than 90 days in those with 0-19 years of age at diagnosis, male gender, cancer treatment at non-private hospitals, diagnoses during the 1990s, more advanced cancer stages, and non-surgical initial treatments. For patients with surgery as the initial treatment, younger age at cancer diagnosis was not significantly associated with increased burden of prolonged treatment delay, unlike for those initially treated with radiotherapy or chemotherapy.

CONCLUSION

By identifying the characteristics of treated cancer patients with higher risk of protracted treatment delay, our findings will inform the national cancer control program to especially target those patients for treatment delay reduction.

Physical late effects of treatment among survivors of childhood cancer in low- and middle-income countries: a systematic review

PURPOSE

Physical late effects of treatment are well-documented among childhood cancer survivors in high-income countries, but whether prevalence and risk factors are comparable in low- and middle-income countries (LMICs) is unclear. We conducted a systematic review to assess physical late effect outcomes among childhood cancer survivors in LMICs.

METHODS

Five health sciences databases were searched from inception to November 2022 in all languages. We included observational studies conducted in LMICs that evaluated physical late effects of treatment in childhood cancer survivors. Mean or median cohort follow-up must have been ≥ 5 years from original cancer diagnosis.

RESULTS

Sixteen full articles and five conference abstracts were included. Studies were conducted in lower-middle (n = 12, 57%) or upper-middle income (n = 9, 43%) countries; nearly half (n = 9, 43%) were conducted in India. Five cohorts (24%) were comprised entirely of 5-year survivors. Subsequent malignant neoplasms were reported in 0-11% of survivors (n = 10 studies). Hypothyroidism and metabolic syndrome prevalence ranged from 2-49% (n = 4 studies) and 4-17% (n = 5 studies), respectively. Gonadal dysfunction ranged from 3-47% (n = 4 studies). Cardiac dysfunction ranged from 1-16% (n = 3 studies). Late effects of the musculoskeletal and urinary systems were least investigated.

CONCLUSIONS

Substantial knowledge gaps exist in LMIC childhood cancer survivorship. No low-income country data were found. In middle-income countries, late effects were defined and assessed variably and limited by selection bias and small sample sizes.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors in LMICs can experience physical late effects of treatment, though additionally systematically collected data from survivor cohorts are needed to fill knowledge gaps.

Multidisciplinary tumor boards in pediatric surgical oncology: a systematic review of approaches in low- and middle-income countries

Pediatric cancer outcomes have improved significantly in recent decades, importantly through multidisciplinary collaboration. Multidisciplinary Tumor Boards (MTBs) foster cross-specialty discussions, leading to refined treatment plans. However, their use in low- and middle-income countries (LMICs) remains underexplored. This systematic review aims to assess existing literature on pediatric MTBs in LMICs to elucidate their current status and identify strategies that enhance their adoption and impact patient outcomes. Following PRISMA guidelines, we searched PubMed, Google Scholar, and SciELO for quantitative and qualitative studies on pediatric MTBs in LMICs. Interventional and observational studies were included, while adult-only research, those set in high-income countries, or lacking results were excluded. Eight out of 2699 studies met inclusion criteria. Risk of bias was assessed using the Newcastle-Ottawa Scale. Collectively, 1063 pediatric patient cases were evaluated, with 90-min MTBs being most common. Attendees included pediatric oncologists, pediatric surgeons, radiologists, radiation oncologists, and pathologists. MTBs improved patient care and standardized treatment. However, LMICs faced challenges such as limited resources, lack of protected time, and unreliable internet access. Despite these barriers, MTBs remain vital for advancing pediatric cancer care in LMICs. Strengthening institutional support and policy frameworks is essential to sustaining and scaling MTBs, ultimately improving cancer care and outcomes for children in resource-constrained settings.

Navigating cancer care in Cameroon: a theory-guided inquiry on patient experiences at Mbingo Baptist Hospital

BACKGROUND

Cancer remains a leading cause of morbidity and mortality globally, with rising incidence rates, especially in low- and middle-income countries (LMICs). This burden is pronounced in Sub-Saharan Africa (SSA), where Cameroon faces escalating cancer challenges, primarily due to inadequate healthcare infrastructure and limited access to early detection and treatment. The study aimed to explore the experiences of cancer patients at Mbingo Baptist Hospital in Cameroon in Cameroon, focusing on the barriers to obtaining quality diagnosis, treatment, and follow-up care, and to examine the impact of these challenges on their physical, emotional, and social well-being.

METHODS

This study employed a qualitative descriptive design, conducting in-depth interviews with eleven cancer patients in December 2023 and January 2024. Participants were selected using purposive sampling, and data were analyzed using thematic analysis to identify key barriers in the cancer care pathway. The biopsychosocial model guided the exploration of patients' experiences, capturing the interplay between biological, psychological, and social dimensions of their healthcare journey.

RESULTS

The analysis revealed significant delays in diagnosis, substantial financial burdens, and emotional and psychological distress among patients. Key themes identified include challenges in the diagnosis and treatment processes, the financial impact of cancer care, emotional and psychosocial repercussions, and difficulties in accessing healthcare services. Despite facing these obstacles, patients also reported instances of resilience and support within their families and communities.

CONCLUSION

The study underscores the urgent need for systemic improvements in cancer care in Cameroon and similar contexts. Enhancing healthcare infrastructure, broadening financial protection, and fostering awareness and early detection are imperative. Additionally, integrating a holistic care approach that considers the biopsychosocial aspects of patient health is crucial for improving outcomes. Addressing these recommendations requires collaborative efforts from governmental and non-governmental organizations, healthcare providers, and the international community to tailor cancer control strategies to the unique needs of LMICs, aiming to alleviate the cancer burden and enhance patient quality of life.

Evaluation of task sharing as a workforce optimization strategy in pediatric oncology

Task sharing is a pragmatic response to the growing shortage of pediatric oncologists globally, especially in low- and middle-income countries (LMICs). However, there have been limited evaluations of how task sharing has been implemented. In this study, we sought to determine the roles and responsibilities of task-sharing physicians (TSPs) in one LMIC, Pakistan. A multicenter cross-sectional study was conducted across 16 hospitals with secondary- to quaternary-level pediatric oncology facilities. An online survey was used to determine task-sharing models, the responsibilities of TSPs, and the level of supervision. Pediatric oncologists were present at 13 of the 16 centers, with a median of 2 pediatric oncologists per center. We found that TSPs included tiers of medical officers/general physicians and pediatricians. They provided inpatient, outpatient, overnight and emergency room coverage. TSPs could participate in defining cancer diagnosis and risk-stratification (n = 9; 56%), selecting initial chemotherapy plans for patients with newly diagnosed cancer (n = 6; 38%) and modifying chemotherapy on the basis of toxicities (n = 6; 38%) under supervision of a pediatric oncologist. In addition, TSPs could write intravenous chemotherapy orders (n = 10; 63%) and prescribe oral chemotherapy (n = 10; 63%). Furthermore, they could independently perform procedures, such as lumbar punctures (n = 15; 94%), intrathecal chemotherapy administration (n = 11; 69%), and bone marrow aspirates and biopsies (n = 11; 69%). TSPs are critical in the pediatric oncology workforce with responsibilities across the pediatric cancer care continuum.

Effects of art therapy on psychological outcomes among children and adolescents with cancer: a systematic review and meta-analysis

BACKGROUND

The increasingly rising incidence of cancer among children and adolescents has led to notable psychological challenges for this population. Art therapy, classified within the realm of complementary and alternative medicine interventions and psychotherapy, demonstrates promising potential psychological benefits for children and adolescents. Therefore, a systematic review was conducted to determine the effects of art therapy on improving psychological outcomes among patients with pediatric cancer and identify the details of art therapy.

METHOD

A systematic review and meta-analysis was conducted. Ten English language databases, two Chinese databases, and grey literature were searched. Two researchers independently conducted study selection, quality assessment and data extraction. The Generic inverse variance method with random-effects models was applied to do meta-analysis.

RESULTS

Three randomized controlled trials (RCTs) and five quasi-experimental studies with acceptable quality involving 452 participants from five countries were included. Our meta-analysis revealed statistically significant improvement in anxiety, depression among pediatric cancer patients. Narrative findings suggested art therapy could improve the overall psychological symptoms, stress, and anger.

CONCLUSION

Art therapy can positively improve psychological outcomes, particularly anxiety and depression. However, the evidence is weakened by limited studies and methodological heterogeneity. Additional high-quality RCTs with large samples are warranted to confirm and supplement the existing evidence.

TRIAL REGISTRATION

This review was registered in PROSPERO with ID CRD42023477700 on 11 November 2023.

Contribution of investment in health and cancer control to economic growth in Commonwealth countries

Background

There are three broad mechanisms through which health investments yield economic benefits. First, health investments in cost-effective innovations help improve health outcomes and reduce healthcare costs in a health system. Second, investments in health can help improve health and wellbeing of individuals. A healthier population is economically more productive, with a longer productive life and reduced absenteeism and presenteeism. Third, an important but often-overlooked mechanism is the benefit of health investments on the broader economy through influences on supply and demand across various other sectors of a country's economy. We examine the third mechanism in selected Commonwealth countries.

Methods

We provide an analysis and estimates of GVA growth and employment effects of the Health Economy for four Commonwealth countries, namely India, Nigeria, Malaysia and the United Kingdom in 2022. Drawing on a conservative 'static estimation approach', whose bases are on the Health Economy Reporting, to provide country-specific assessment of the return on investment in cancer services and cancer prevention in the UK, for which data are available, as an illustrative 'use case'. For cancer prevention, we examine investments in vaccination for Human Papilloma Virus.

Findings

In our analysis, the Gross Value Added (GVA) generated by the Health Economy in the UK amounted to about US$295 billion (8.9% of GDP; the largest sector by size) in 2022, with around US$171 billion of GVA (5.2% of GDP) generated in adjacent sectors, and through these two effects generating additional induced consumption of US$217 billion of GVA (6.6% of GDP). In India, Malaysia, and Nigeria, in 2022, total GVA generated by the Health Economy, adjacent sectors and through induced income accounted for 9.9%, 9.8% and 7.0% of the GDP respectively. In the UK, US$134 million of investment in HPV vaccination generated US$247 million of GVA in total and 2000 jobs. Whereas in India US$756 million of investment in HPV vaccination produced US$ 1149 million in total GVA and generated 155,000 jobs.

Interpretation

The assessment of four Commonwealth countries reveals that the Health Economy contributes substantially to economic growth and generates substantial employment. These contributions extend beyond the health sector itself, reaching adjacent sectors along the health value chain and inducing effects throughout the broader economy. Investment in cancer prevention generates high returns with substantial addictions to GVA and employment.

Funding

No external funding. Self-funded by Harvard University and Wifor Institute.

Childhood cancer surgery in low- and middle-income countries

This report summarizes the status of pediatric surgical oncology services in low- and middle-income countries. Factors such as surgical capacity and enablers, and barriers to providing pediatric surgical oncology services are discussed. A review of the literature was conducted to examine the evidence for the capacity of low- and middle-income countries to provide childhood cancer surgery services, focusing on general surgery. Unpublished, ongoing work and initiatives of international organizations are also described.

Impact of Internet Addiction on Patient-Reported Outcomes in Chinese Children Aged 8 to 18 Years With Malignant Tumors: A Cross-Sectional Study

Background In the context of the digital era, the deep integration of the Internet and the medical field has shown two sides in the treatment and rehabilitation of children with malignant tumors. However, the problem of Internet addiction (IA) behind Internet use in these children - and its potential threat to their health status - has not yet attracted widespread attention. The main objective of this study was to investigate the impact of IA on patient-reported outcomes (PROs) in Chinese children aged 8 to 18 years with malignant tumors. Methods From October 2023 to May 2024, a continuous sampling of 300 children aged 8 to 18 with malignant tumors was conducted at the National Clinical Medical Research Center for Child Health and Diseases in Chongqing. IA was assessed using the Internet addiction test (IAT). In contrast, the Chinese version of the Pediatric Patient-Reported Outcome Measurement Information System (C-Ped-PROMIS) was used to evaluate the PROs. The relationship between these variables was analyzed using Spearman rank correlation analysis and multiple linear regression models. Results Out of 300 children, 87 (29.0%) showed signs of IA, with elementary school students having a significantly lower rate than students in middle school and above (p = 0.005). IA was positively correlated with depression (r = 0.127, p < 0.05), anger (r = 0.130, p < 0.05), anxiety (r = 0.158, p < 0.01), and fatigue (r = 0.129, p < 0.05) scores. Multiple linear regression analysis showed that elevated IAT scores were significant negative predictors of depression, anger, anxiety, and fatigue (all p < 0.05). Conclusion Children aged 8 to 18 years with malignant tumors face a higher risk of IA, which is closely related to some self-reported outcomes. Healthcare professionals should pay attention to the Internet usage issues of children with malignant tumors, guiding them to use the Internet wisely to improve their mental health and overall well-being.

Parents' Experiences of Palliative Care Decision Making for Children With Terminal Cancer: A Qualitative Study

The objective of this study was to describe the experiences and perceptions of parents making palliative care decisions for children with end-stage malignancies. This qualitative study was conducted with 13 parents from 9 families of children with end-stage malignant tumors. Data were analyzed using thematic content analysis. Three interrelated themes were identified: (1) parental knowledge of the child's condition influences palliative care decision making, (2) the establishment of a mutually trusting relationship between parents and health care professionals is key to implementing palliative care decision making, and (3) the influence of family background and traditional culture on parental palliative care decision making. This study adds to the evidence related to parents' experiences of end-of-life care decision making and provides findings of international significance, particularly concerning the place of care and the introduction of end-of-life care discussions. Parents' expert knowledge of their child's condition is important and should be recognized. End-of-life care decision making is a complex and delicate process; each family's information needs and preferences are individualized and need to be understood by the professionals involved in care.

Exploring Pediatric Oncology Care Practices Influencing the Relationships Among Children, Caregivers, and Health Care Providers: A Multi-Institutional Study From Pakistan

PURPOSE

The quality of relationships between health care professionals (HCPs) and patients is an important factor influencing people's experiences with their health systems. In Pakistan, pediatric oncologists highlight the need for effective communication to support relationships between HCPs and children and families. Existing communication toolkits on the basis of the evidence from high-income countries are ineffective and culturally unsuitable in the context of low- and middle-income countries. Therefore, we aim to describe how characteristics of current pediatric oncology care practices for children with life-threatening illnesses (LTIs) influence their relationships and communication about illness and treatment.

MATERIALS AND METHODS

A phenomenological qualitative study was conducted. In-depth interviews (N = 60) were conducted with children (8-18 years) with LTI receiving treatment at one of three pediatric oncology units in Karachi, their families, and HCPs. Themes were generated after inductive coding.

RESULTS

Five themes were identified, and four key findings are highlighted. First, HCPs valued effective communication. Practices were influenced by the sociocultural environment using a range of approaches, often without formal training, to respond to local needs. Second, families and HCPs were concerned about treatment-related fears, leading to reluctance in sharing illness information with children regardless of age. Third, both groups felt that disclosing diagnosis, involving families and children in treatment plans, and age-appropriate communication would strengthen the therapeutic alliance. Finally, HCPs emphasized the importance of faith and a multidisciplinary team approach in enhancing therapeutic relationships.

CONCLUSION

The need for effective communication with children with LTI and families while respecting sociocultural norms will allow for trust building and stronger therapeutic alliances.

Exploring Barriers and Inequalities in Access to Comprehensive Care for Pediatric Oncology Patients: A Systematic Review

OBJECTIVES

This systematic review aimed to explore and synthesize existing research on the barriers and inequalities in access to comprehensive care for pediatric oncology patients.

METHODS

The search was conducted in five databases, including PubMed, Scopus, Web of Science, CINAHL, and APA PsycINFO in December 2024. This review followed PRISMA guidelines and included studies published up to December 2024. Study quality was assessed using Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields.

RESULTS

Thirteen articles in this systematic reviews identified key barriers to healthcare access, including inadequate infrastructure, workforce shortages, and financial constraints. Socioeconomic disparities, geographic inequities, and racial and ethnic inequalities further exacerbated these challenges. Lower family income was linked to worse outcomes, such as higher chronic graft-versus-host disease rates and late-stage cancer diagnoses. Cross-border residency, clinical trial underrepresentation, and insufficient clinician training also contributed to disparities. Proposed solutions included psychosocial screening, workforce development, financial toxicity mitigation, and policy reforms.

CONCLUSIONS

This review highlights the complex and multifaceted barriers affecting equitable access to comprehensive care for pediatric oncology patients. Using a multidimensional perspective, such as the National Institute on Minority Health and Health Disparities Research Framework, our findings suggest that disparities stem from interconnected social, economic, and systemic factors. Addressing these challenges requires a comprehensive, structural, and patient-centered approach to promote equitable healthcare access.

IMPLICATIONS FOR NURSING PRACTICE

This review underlines the critical role of nursing advocacy, education, and interdisciplinary collaboration in promoting equitable care and addressing disparities within this vulnerable population.

Global, regional and national burden and quality of care index (QCI) of leukaemia and brain and central nervous system tumours in children and adolescents aged 0-19 years: a systematic analysis of the Global Burden of Disease Study 1990-2019

OBJECTIVES

This study aimed to evaluate the global, regional and national disparities in the quality of care for leukaemia and brain and central nervous system (CNS) tumours among children and adolescents aged 0-19 years. We also assessed temporal trends in the quality of care index (QCI) and explored associations with sociodemographic development levels, gender and age.

SETTING

The study used data from the Global Burden of Disease (GBD) 2019 database, covering 204 countries and territories. The analysis included global, regional and national levels of care, stratified by sociodemographic index (SDI), gender and age groups.

PARTICIPANTS

The study included children and adolescents aged 0-19 years diagnosed with leukaemia or CNS tumours. Data on incidence, prevalence, mortality and disability-adjusted life years (DALYs) were extracted from the GBD 2019 database.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the QCI, constructed using principal component analysis from four secondary indicators: years of life lost to years lived with disability ratio, DALYs to prevalence ratio, mortality to incidence ratio and prevalence to incidence ratio. Secondary outcomes included temporal trends in QCI, gender disparity ratios (GDRs) and correlations between QCI and SDI levels.

RESULTS

In 2019, leukaemia and CNS tumours accounted for 132 194 deaths globally. The QCI for leukaemia was 74.71, while for CNS tumours, it was 56.59. From 1990 to 2019, the QCI for CNS tumours increased significantly (estimated annual percentage change (EAPC)=1.45, 95% CI: 1.41 to 1.50), whereas the QCI for leukaemia showed a declining trend in middle and low-middle SDI regions (EAPC=-0.13, 95% CI: -0.16 to -0.09). Western Europe had the highest QCI for leukaemia (94.50), while South Asia had the lowest (57.64). Boys had lower QCI scores than girls, and the gender disparity in CNS tumours widened over time (GDR increased from 1.147 in 1990 to 1.160 in 2019). QCI was positively correlated with SDI levels (leukaemia: r=0.591, p<0.001; CNS tumours: r=0.812, p<0.001).

CONCLUSIONS

This study highlights significant disparities in the quality of childhood cancer care across regions, development levels and genders. While global QCI for CNS tumours improved, leukaemia care quality declined in middle and low-middle SDI regions. Boys and populations in low SDI regions are particularly vulnerable to poor care. Policymakers should prioritise targeted interventions to address these disparities, improve access to quality care and reduce the global burden of childhood cancer.

The St. Jude Global Academy: A Multifaceted Education Program to Expand Pediatric Oncology Workforce Capacity

There is currently a global shortage of healthcare professionals equipped to handle the rising burden of childhood cancer. St. Jude Global is an initiative to improve survival rates of children with cancer worldwide while improving access to quality care. One of the overriding goals of St. Jude Global is focused on education: the training of the clinical workforce needed to expand quality care for all children with cancer. Herein, we describe the St. Jude Global Academy (SJGA) and its programs. The three main workstreams of the SJGA are: clinical training programs, courses, and distance learning. St. Jude collaborates with eight institutions in seven low- and middle-income countries to train pediatric subspecialists. Each year, approximately 20 new fellows start at these clinical training programs. To date, 92 specialists have been trained. The SJGA's courses create educational opportunities that provide a structured learning experience in key areas that are relevant to pediatric cancer care. To date, 1081 participants from 372 institutions in 84 countries have successfully completed these educational opportunities. Cure4Kids is the SJGA's distance learning platform. Over 9000 healthcare professionals in 177 countries use Cure4Kids. The platform receives 1400 visits and over 13,000 page views per day. The SJGA's multifaceted approach encompasses various disciplines and skills, providing healthcare professionals from around the world the skills to address the needs of children diagnosed with cancer in their respected institutions. These efforts are essential for building workforce capacity to improve outcomes.

A case control analysis of pattern and risk factors for pulmonary dysfunction amongst childhood cancer survivors: a single centre study from a low-middle income setting

Pulmonary toxicity is one of the most common morbidities experienced by childhood cancer survivors (CCS). The aim of this study was to identify prevalence, pattern of dysfunction, and risk factors among CCS and compare with age and sex matched controls. Details of demographic and pulmonary-toxic treatment of CCS at least 2 years off-treatment were collected and a cross-sectional analysis of pulmonary function test (PFT) and risk factors was performed. Spirometry findings were categorized as normal, restrictive, or obstructive and diffusing capacity of carbon monoxide (DLCO) as normal or abnormal. PFT data of 192 CCS and 50 controls was analyzed. One or more abnormalities inspirometry or DLCO were observed among 112 (58.3%) CCS and 8 (16%) controls (p value <0.01). Abnormal PFT was more likely to be associated with older age at evaluation, longer follow-up, and use of chest-directed radiotherapy (p value 0.002, 0.02, 0.03). DLCO was the most common abnormality observed in 85 (44%) patients. Obstructive and restrictive patterns were observed in 66 (34.3%) and 42 (21.8%) survivors respectively. There was no correlation between any risk factor and specific pattern of pulmonary dysfunction. On univariate analysis age at evaluation >20 years, follow-up >10 years, cumulative bleomycin more than 120 mg/m2, chest-directed radiotherapy, surgery, and female gender were found to be predictive for abnormal PFT. On multivariable analysis first four factors retained significance. High subclinical prevalence among CCS especially in older patients with longer follow-up mandates longitudinal follow-up to assess long-term pulmonary outcome and plan intervention strategies for this subset.

International accreditation of a pediatric hematology/oncology fellowship program in Guatemala: a quantitative assessment

PURPOSE

High-quality graduate medical education programs are essential to expand the care available to children with cancer worldwide. The authors used the Education Program Assessment Tool (EPAT), a standardized tool for evaluating pediatric hematology/oncology (PHO) fellowship programs, to describe the impact of the Accreditation Council for Graduate Medical Education International (ACGME-I) accreditation process.

METHODS

The EPAT is a comprehensive, validated tool for evaluating the elements of PHO fellowship programs. The authors used the EPAT in May 2018 and December 2023 to compare the pre-accreditation and post-accreditation status of the Unidad Nacional de Oncología Pediátrica (UNOP) PHO fellowship program.

RESULTS

The authors used the EPAT to identify program gaps and to prioritize interventions to meet ACGME-I accreditation standards. Before accreditation, the overall score of the UNOP PHO fellowship program was 77.2%. The highest score was for Hospital Infrastructure (86.4%) and the lowest score was for Research (63.0%). After accreditation, the overall score was 88.3%. Eight of the 10 EPAT domains had higher post-accreditation scores, with a significant improvement in domain scores overall (P < 0.0001) (Fig. 2). In alignment with the improvement workstreams, the Educational Infrastructure and Evaluation domains had the greatest increases in scores (27% and 25%, respectively). Research continued to have the lowest score (75.9%), but this was improved by 13%.

CONCLUSIONS

This study provides quantitative data on the enhancement of a PHO fellowship program in a middle-income country after the process ACGME-I accreditation based on the improvement of EPAT scores. Additional analyses and evaluation tools are needed to identify strategies optimize training approaches and to meet the evolving accreditation standards for health care around the world.

Childhood Cancer Survivorship Care in Limited Resource Settings: A Narrative Review and Strategies to Promote Global Health Equity

The WHO Global Initiative for Childhood Cancer, prompted by the marked inequity of survival across the globe, aims to increase survival rates in low- and middle-income countries to 60% by 2030. In tandem with this effort, implementing survivorship-focused care is crucial to mitigate late effects and prevent early mortality beyond the 5-year survival end point. The observed burden of secondary malignancies, cardiovascular disease, and other chronic health conditions in adult survivors of childhood cancer in high-income countries provides guidance to generate evidence in limited-resource settings. The implementation of risk stratification tools, population health management, and development of contextually relevant health care delivery models, within the current landscape of survivorship care in Latin America, Africa, and Asia as examples, are vital to continue the momentum to ensure equitable care and quality of life for all survivors of childhood cancer. This narrative review informed by expert opinion serves as a call to action for survivors, advocacy groups, health professionals, health systems, governments, and global organizations to look beyond the 5-year survival benchmark.

Living With Cancer: Child-Parent Dyads' Perspectives and Experiences From a Private Tertiary Care Hospital in Pakistan

The life experiences of children with cancer and their parents as individuals have been well documented in literature. However, little is known about their experiences as child-parent dyads in Pakistan regarding these children's quality of life. Thus, the study was conducted in the context of the family-centric society of Pakistan. In-depth interviews were conducted with 28 participants (14 child-parent dyads), comprising 9 female and 5 male children receiving cancer treatment and 8 mothers and 6 fathers (primary caregivers). All the participants were Muslims and hailed from diverse ethnic backgrounds, and most belonged to middle socioeconomic backgrounds. Thematic analysis was performed using Braun and Clarke's (2006) framework, which revealed four themes: (1) Stress, Fears, and Optimism; (2) Reactions to Restrictions; (3) Adaptation and Coping; and (4) Support Structure and Mechanisms. The findings indicated that children's and parents' daily lives were affected in various ways during the children's cancer journey. They faced several challenges which impacted their well-being. Particularly, the children considered their symptoms as restrictions in the way of carrying out their routine lives. However, children and parents also elaborated on using different coping strategies, such as play, reminiscing the past, incorporating religious practices into their daily routines, and keeping a family-centred approach towards the child's care. The parents also recommended that cancer-specialised services and support groups should be accessible. Conclusively, these findings are useful for healthcare providers in giving family-centred care to afflicted families and devising innovative interventions that address the needs of children with cancer and improve their quality of life.

Whole-Body MRI in Children: Concepts and Controversies-AJR Expert Panel Narrative Review

The use of whole-body MRI (WBMRI) in children, from infancy to adolescence, has expanded rapidly over the past decade, with increasing uptake and a broadening range of clinical indications. Current indications include screening for presymptomatic lesions in cancer predisposition syndromes; tumor staging in known malignancies; investigating fevers of unknown origin; as well as diagnosing and monitoring rheumatologic diseases, vascular anomalies and neuromuscular disorders. This AJR Expert Panel Narrative Review aims to offer a comprehensive discussion of WBMRI in pediatric patients, exploring protocols and other technical considerations, clinical indications, implementation challenges and troubleshooting, as well as controversies in widespread adoption, while considering emerging trends and directions. Commonalities and variations in WBMRI protocols across indications and institutions are presented, highlighting the need for greater standardization. Barriers to WBMRI access, particularly in resource-limited settings, are considered, along with potential solutions. The available evidence regarding potential patient benefit from WBMRI across various applications is summarized.

Landscape of Global Pediatric Oncology Publications: A Cross-Sectional Analysis

PURPOSE

The academic field of global pediatric oncology is expanding as cancer becomes increasingly recognized as a global health priority for children and adolescents. Here, we aimed to explore the representation of authors, the geographic distribution of research, and the research approaches being used in global pediatric oncology.

METHODS

Articles published in JCO Global Oncology (JCO GO) and Pediatric Blood and Cancer on the topic of global pediatric oncology were analyzed. For each article, data were collected on the study design, the research location, and the authorship demographics. Descriptive frequencies were reported for all items.

RESULTS

Overall, 296 studies met the inclusion criteria to be considered relevant for global pediatric oncology. Of these, 259 (87.5%) were research articles. Of the research articles, 228 (88.0%) were observational and 117 (51.3%) were retrospective cohort analyses. Thirty-eight studies (12.8%) had a global focus or were unrelated to a geographic context, 54 (18.2%) were regional, and 204 (68.9%) were specific to a single country. Females represented 163 (55.8%) of first authors, 138 (46.6%) of senior authors, and 159 (53.7%) of corresponding authors. Furthermore, 121 (41.4%) first authors, 163 (55.1%) last authors, and 142 (48.0%) senior authors were from high-income countries (HICs). The United States (n = 81) and India (n = 40) had the most corresponding authors. Thirty-six (17.6%) articles had research conducted in low- and middle-income countries (LMICs), and the first, senior, and corresponding authors were from HICs.

CONCLUSION

Our analysis shows that researchers from LMICs are under-represented as authors of global pediatric oncology publications. Further studies are needed to evaluate the factors that contribute to inequalities in global pediatric oncology research.

Global, regional, and national burden of acute lymphoblastic leukemia in children: Epidemiological trends analysis from 1990 to 2021

Children are the main susceptible group to acute lymphoblastic leukemia (ALL), and the lack of sufficient data has impeded a comprehensive understanding of its global impact. This study analyzed the annual numbers and rates of incidence, deaths, and disability-adjusted life years (DALYs) of childhood ALL from 1990 to 2021, disaggregated by age group, gender, and socio-demographic index (SDI) at the global, regional, and national levels, based on the 2021 Global Burden of Disease (GBD) database. Although global deaths and DALYs rates for childhood ALL showed declining trends, the incidence rate fluctuated. Incidence rates in high SDI regions were higher, but deaths and DALY rates were lower. Moreover, the burden in Sub-Saharan Africa and other low SDI countries was growing. The burden on boys has been higher than on girls in this period. This study underscored improving prevention and treatment measures are critical to control the persistent global burden of children ALL.

"It's his cheerfulness that gives me hope": A qualitative analysis of access to pediatric cancer care in Northern Tanzania

Pediatric cancer is a significant and growing burden in low- and middle-income countries. The objective of this project was to describe the factors influencing access to pediatric cancer care in Northern Tanzania using the Three Delays Model. This was a cross-sectional qualitative study conducted between June and August 2023 at Kilimanjaro Christian Medical Centre (KCMC). Using purposive sampling methods, caregivers of children obtaining pediatric cancer care at KCMC were approached for participation in in-depth interviews (IDIs) and a demographic survey. All IDIs were facilitated in Swahili by a bilingual research coordinator. Analysis utilized inductive and deductive coding approaches to identify dominant themes and sub-themes impacting access to pediatric oncology care. Data collection concluded once saturation was achieved at 13 IDIs, defined as the absence of new codes after three consecutive interviews. Participants reported significant financial barriers to accessing pediatric cancer care along the entire care continuum. In the first delay, themes included waiting for symptoms to resolve and the identification of initial symptoms. The most substantial delays occurred in delay 2, including health infrastructure at mid-level facilities, misdiagnoses, the referral system, travel, and traditional medicine. Participants did not describe delays after arrival to KCMC and rather offered perspective on their child's cancer diagnosis, their concerns while obtaining care, and their hopes for the future. Financial support provided by the Tanzanian government was the only facilitator noted by participants. We suggest targeted interventions including 1) empowerment of CHWs and local traditional healers to advocate for earlier care seeking behavior, 2) implementation of clinical structures and training at intermediary medical centers aimed at earlier referral to a treatment facility, 3) incorporation of support and education initiatives for families of children with a cancer diagnosis. Lastly, national health plans should include pediatric cancer care.

Inequities in childhood cancer research: A scoping review

An integral part of understanding and then designing programs to reduce childhood cancer inequities includes adequate representation of people with cancer in research, including children. A scoping review was carried out to understand how cancer research is oriented toward inequities and to identify who has participated in childhood qualitative cancer research. A systematic search identified 119 qualitative studies that met inclusion criteria, with most studies taking place in high-income countries (n=84). Overall, data were lacking on social determinants of health at multiple levels-structural, household, child, and guardian. Only 29 studies reported on race and/or ethnicity, with the majority of those including predominantly or all white children. Six articles included socioeconomic information, and across most articles, attention was absent to the financial ramifications of cancer care. Limited reporting of sociodemographics highlights a broader issue of neglecting key demographics and social factors that contribute to inequities.

Organization of shared care networks and their role in overcoming challenges and enhancing outcomes for childhood cancer: A systematic review

This systematic review examines shared care networks (SCNs) in pediatric oncology as a strategic response to the healthcare challenges in low- and middle-income countries. SCNs integrate specialized hubs with local satellite centers to enhance accessibility and quality of care. Our methodology included a search of PubMed, Embase, Google Scholar, and Scopus, selecting peer-reviewed articles from the last 20 years. We analyzed nine studies, focusing on SCN definitions, models, and outcomes. Findings reveal that SCNs improve clinical outcomes and patient satisfaction, while reducing economic and emotional burdens through standardized protocols and efficient referral systems. Despite the benefits, challenges remain in maintaining consistent care quality and communication across centers. The review underscores the need for further research to quantify benefits, examine long-term outcomes, and refine operational practices to optimize SCNs' effectiveness in pediatric oncology.

Exploring treatment decision-making at diagnosis for children with advanced cancer in low- and middle-income countries

PURPOSE

Global childhood cancer survival outcomes correlate with regional contextual factors, yet upfront treatment decision-making for children with advanced or poor prognosis cancer in low- and middle-income countries (LMICs) is not well understood. This study aimed to (1) characterize the landscape of contextual factors that shape physician decision-making at diagnosis for these children in LMICs and (2) describe physician rationales for if/when to offer treatment with non-curative intent, including how they define "poor prognosis" during treatment decision-making.

METHODS

An international panel of pediatric oncologists practicing in LMICs participated in two focus groups structured for the collaborative generation of factors influencing treatment decision-making, including consideration of non-curative treatment pathways at diagnosis. Thematic analysis of qualitative data was conducted, followed by member checking.

RESULTS

Eleven pediatric oncologists participated, representing all global regions defined by the World Health Organization. Participants identified a broad range of factors influencing decision-making across multiple levels, including the individual, hospital, health system, community, and country levels. All participants agreed that treatment with non-curative intent could be offered at diagnosis in certain contexts, and diverse definitions for poor prognosis were described.

CONCLUSIONS

Upfront treatment decision-making for children with advanced or poor prognosis cancer in LMICs is variable and challenging. Difficulties with decision-making in LMICs may be amplified by inconsistent definitions of poor prognosis and underrepresentation of the factors that influence treatment decision-making within existing decision-making frameworks or childhood cancer treatment guidelines. Future research should explore decision-making approaches, preferences, and challenges in depth from the perspectives of pediatric cancer patients, families, and multidisciplinary clinicians.

Challenges and coping strategies among caregivers of children with cancer receiving care at a national referral hospital in Kenya

BACKGROUND

The number of children diagnosed with cancer is expected to increase by 2050. The caring aspect of these children is usually left to members of the family, more so the mothers. Caregivers are usually faced with various challenges, such as financial issues, social stigma, and emotional and psychological issues. Caregivers use various coping strategies to manage the challenges they experience in the caring process, which can be positive or negative coping strategies.

OBJECTIVE

To explore the challenges and coping strategies of caregivers of children with cancer receiving care at a national referral hospital in Kenya.

METHODS

This study employed a descriptive phenomenological approach to explore the challenges and coping strategies of caregivers of children with cancer receiving treatment at a national referral hospital in Kenya. Purposive and snowball sampling techniques were used to select 44 participants for five focus group discussions (FGDs) conducted between October and December 2023. The data were analysed via inductive thematic analysis.

RESULTS

Four themes arose from the challenges experienced, which included psychological, financial, treatment-related, and social/family-related issues. These eleven subthemes included stress, depression, lack of transport, lack of food, loss of employment, treatment delays, and marital issues, among others. Two themes related to coping strategies were positive adaptation and denial, which were highlighted as negative coping strategies. Positive coping included praying, crying, talking to people, and seeking help.

CONCLUSION

Caregivers of children with cancer undergo various challenges and apply various coping strategies to try and adapt to their new normal. Reinforcing positive coping strategies and helping caregivers utilize other coping strategies, such as the use of support groups, could help them better care for their children.

The Predictive Power of Religious Coping on Care Burden, Depression, Stress, and Anxiety of Parents of Pediatric Oncology Patients in Turkey

This study aimed to determine the predictive power of religious coping of parents of children with cancer on caregiver burden, depression, anxiety, and stress in Turkey. It was designed as a descriptive and cross-sectional study, utilizing correlational analysis and regression models to explore associations between variables. Data were collected from 164 parents in the pediatric hematology-oncology clinics of a university hospital between November 2023 and March 2024. There was a negative correlation between caregiver burden score and negative and positive religious coping scores. Caregiver burden scores were positively correlated with depression, anxiety, and stress scores. Results indicated that caregiver burden, education level, employment status, family structure, family income, and age at diagnosis significantly predicted positive religious coping. For negative religious coping, caregiver burden, education level, family structure, and family income were significant predictors. This suggests that religious coping may help reduce caregiver burden, underscoring the importance of promoting constructive coping strategies to support caregivers' well-being.

Electronic Patient Reported Outcomes Measures (e-PROMs) in Pediatric Palliative Oncology Care: A Scoping Review

Objective: Research findings regarding child-centered care and electronic patient reported outcome measures (e-PROMs) within pediatric palliative oncology care reveal an intricate field of study. This study aimed to map innovations in e-PROMs for the pediatric cancer population in palliative care and their impact on symptom management, and communication with healthcare professionals. Methods: A scoping review was designed following the Arksey and O'Malley framework. Literature searches were conducted in CINAHL, Embase, MEDLINE, PsycINFO, SCOPUS, and Web of Science. Inclusion criteria targeted children aged 0-18 years with cancer, receiving palliative and/or end-of-life care, and using e-PROMs. Results: Twelve articles were included: 10 quantitative studies, one qualitative study, and one mixed-method study. A narrative synthesis approach was used to summarize the findings, categorized into three sections: (a) technological innovation of e-PROMs in pediatric palliative oncology care; (b) the impact of e-PROMs on symptom monitoring, management, and children's care; (c) the effects of e-PROMs on communication between children and healthcare professionals in pediatric palliative oncology care. Conclusion: e-PROMs have proven effective in empowering children to express their perspectives and actively engage in their end-of-life care. Due to flexible software and devices designed for various age groups, these tools fit seamlessly into children's daily routines and preferences, including the use of play-oriented applications. They facilitate a deeper understanding, and management of physical and emotional symptoms while ensuring care remains child-centered. This emphasizes the importance of preserving the essence of childhood and addressing the unique needs and experiences of young patients in pediatric palliative oncology care.

Survival analysis of haematologic neoplasms in children and adolescents: a population-based study in a state of the Brazilian Legal Amazon

Aims

To estimate the survival patterns of childhood leukaemias and lymphomas in Mato Grosso between 2001 and 2017.

Methods

Retrospective population-based cohort study, with case information extracted from the population-based cancer registries (PBCRs) of Mato Grosso for the period 2001-2017. Cases aged 0-19 years diagnosed with microscopically confirmed leukaemias or lymphomas were eligible. Five-year relative survival was calculated using the Eldererer II method, considering the interval between diagnosis and death, loss to follow-up or censoring, after passive follow-up in the mortality information system. Cases registered only by death certificate were excluded.

Results

510 cases of leukaemia were analysed, with a predominance of males (56.1%) and an age range of 0-4 years (34.9%). The 5-year relative survival rate was 77.3% (95% CI: 73.6;80.9). As for lymphomas, there were 261 cases, predominantly in males and in the age group 5-9 years. The 5-year relative survival rate was 84.7% (95% CI: 78.3;88.9), with a better prognosis for females and 87.7% (95% CI: 80.8;95.1) in the 5-9 years age group.

Conclusion

The relative survival rates of childhood leukaemia and lymphoma in the state of Mato Grosso were lower than those of developed countries. The importance of early diagnosis and timely treatment for better outcomes is highlighted. The importance of using and continuously improving the quality of information from PBCRs in the state of Mato Grosso is highlighted.

Evaluating implementation of a hospital-based cancer registry to improve childhood cancer care in low- and middle-income countries

PURPOSE

Cancer is a leading cause of global childhood mortality, affecting 400,000 children annually. While treatable with modern therapies, children living in low- and middle-income countries (LMICs) have limited access to care and lower survival rates. Hospital-based cancer registries (HBCRs) collect detailed patient information to critically evaluate and evolve care. The St. Jude Global Childhood Cancer Analytics Resource and Epidemiological Surveillance System (SJCARES) is a cloud-based HBCR network facilitating quality data collection of pediatric cancer. Wide variation in the success of implementation has warranted further research into the implementation approach, to create a sustainable and adaptable HBCR in LMICs.

METHODS

Seven of 89 sites using the SJCARES registry were selected, stratified by global region and stage of implementation. Semi-structured interviews were conducted with key groups (clinicians, administrators, data clerks) using an interview guide developed from the Consolidation Framework for Implementation Research (CFIR). Interviews were conducted via a video-telephone software program and transcribed by a transcription service. Transcripts were thematically coded using rapid qualitative analysis.

RESULTS

A total of 18 participants (11 clinicians, 4 administrators, 3 data clerks) were interviewed. Several barrier themes were identified, including: difficulty integrating the registry into existing workflow; lack of resources; lack of government or administrative support; and damaged, misplaced, or illegible medical records. Facilitator themes were identified, including: internal support for the registry; clear and extensive training; and dedicated support staff.

CONCLUSION

Interviewed participants identified key barriers and facilitators to the implementation of the SJCARES registry across multiple phases. We plan to use these results to develop targeted implementation strategies including a readiness assessment tool to help guide more successful implementation of the SJCARES registry and other HBCRs in LMICs.

Towards attainment of the 2030 goal for childhood cancer survival for the World Health Organization Global Initiative for Childhood Cancer: An ecological, cross-sectional study

The World Health Organization (WHO) recently launched the Global Initiative for Childhood Cancer (GICC), with the goal of attaining at least 60% cancer survival for children worldwide by the year 2030. This study aims to describe the global patterns of childhood cancer survival in 2019 to help guide progress in attaining the GICC target goal. In this ecological, cross-sectional study, we used 5-year net childhood cancer survival (2015-2019) data from a prior micro-modeling study from 197 countries and territories. Descriptive statistics were used to analyze the patterns of overall childhood cancer survival and survival for each of the six cancer tracer diagnoses as proposed by the GICC. We used hot spot analysis to identify geographic clusters of high and low cancer survival. Most high-income countries reached at least 60% (92%, n = 59/64), net childhood cancer survival at baseline. No lower-middle-income or low-income country reached at least 60% overall cancer survival at baseline. The South-East Asia region had the highest proportion of countries that did not achieve at least 60% survival at baseline (100%, n = 10/10), followed by the African region (98%, n = 49/50). For each cancer tracer diagnosis, we found the highest number of countries that have achieved at least 60% survival was for Burkitt lymphoma (44%, n = 87/197) followed by acute lymphocytic leukemia (41%, n = 80/197).Hot spot analysis showed the highest overall survival was concentrated in North America and Europe, while the lowest survival was concentrated in Sub-Saharan Africa and South-East Asia.A majority of LMICs had not reached the WHO target goal of at least 60% survival from childhood cancer at baseline in 2019, with variable success for the six childhood cancer tracer diagnoses of the GICC. These findings provide baseline assessment of individual country performance to help achieve the GICC goal of 60% overall cancer survival globally by 2030.

Exploring the lived experience of mothers of children with leukemia: a qualitative study from Iran

BACKGROUND

Leukemia, as one of the most common pediatric cancers, has negatively affected many children around the world. Parents often experience increased feeling of distress shortly after being informed about their child's diagnosis. The distress experienced by parents can adversely affect various aspects of their life. This study aimed to develop an understanding of the lived experience of the mothers whose children suffer from leukemia in Shiraz, Iran.

METHODS

This phenomenological study was performed from April to August 2023, and 10 people were selected as participants by purposive sampling. In-depth and semi-structured interviews were performed for collecting the data.

RESULTS

The participants' lived experiences during their children's leukemia were classified into five main categories, namely behavioral problems, spiritual issues, psychological problems, issues related to treatment, and economic matters.

CONCLUSION

Knowing the experiences of parents, especially mothers, in managing and planning for the care of these children seems essential.

Estimation of the optimal radiotherapy utilization rate for childhood neuroblastoma

BACKGROUND AND PURPOSE

The optimal utilization rate of radiotherapy (oRUR) serves as a benchmark for assessing service demand and improving access to cancer care. While it is estimated that approximately 50 % of adult cancer patients require external beam radiotherapy during their treatment, there is a scarcity of data regarding the optimal use of radiotherapy in pediatric cancer. In this study, we adopted an established method and developed a model to estimate the oRUR in childhood neuroblastoma.

MATERIALS AND METHODS

We developed a decision tree model to calculate the oRUR using indications for radiotherapy and corresponding epidemiological data collected through systematic review and meta-analysis. Sensitivity analyses were performed to evaluate the impact of variations in radiotherapy indications between treatment protocols and variables in the model. We calculated and compared the oRUR for global, high-income, and low- and middle-income settings.

RESULTS

The oRUR for pediatric neuroblastoma was 64 % (95 % CI: 58 %-71 %) in the global setting, 50 % in high-income countries, and 68 % in low- and middle-income countries. The impact of variation in radiotherapy indications between major international treatment protocols was negligible.

CONCLUSION

The knowledge of oRUR is crucial for evaluating current practices, identifying gaps in access, and planning future radiotherapy services for treating childhood cancer. Based on our results, 64 % of children with neuroblastoma have an indication for radiotherapy. Patients in low- and middle-income countries have more indications for radiotherapy than those in high-income countries, due to a more adverse tumour stage distribution caused by limited access to healthcare resources.

Diagnostic and treatment strategies for pediatric acute lymphoblastic leukemia in low- and middle-income countries

The survival rate of children and adolescents with acute lymphoblastic leukemia (ALL), the most common pediatric cancer, has improved significantly in high-income countries (HICs), serving as an excellent example of how humans can overcome catastrophic diseases. However, the outcomes in children with ALL in low- and middle-income countries (LMICs), where approximately 80% of the global population live, are suboptimal because of limited access to diagnostic procedures, chemotherapeutic agents, supportive care, and financial assistance. Although the implementation of therapeutic strategies in resource-limited countries could theoretically follow the same path of improvement as modeled in HICs, intensification of chemotherapy may simply result in increased toxicities. With the advent of genetic diagnosis, molecular targeted therapy, and immunotherapy, the management of ALL is changing dramatically in HICs. Multidisciplinary collaborations between institutions in LMICs and HICs will provide access to strategies that are suitable for institutions in LMICs, enabling them to minimize toxicities while improving outcomes. This article summarizes important aspects of the diagnosis and treatment of pediatric ALL that were mostly developed in HICs but that can be realistically implemented by institutions in countries with limited resources through resource-adapted multidisciplinary collaborations.

Novel Framework of Financial Hardship in Childhood Cancer: Incorporating Stakeholder Perspectives

PURPOSE

Although financial hardship in childhood cancer contributes to poor outcomes, no standardized tool to assess its impact exists. Existing methods are heterogeneous and designed using high-income country (HIC), adult perspectives. This project aimed to construct a stakeholder-informed conceptual framework of financial hardship in childhood cancer with global relevancy.

METHODS

Group concept mapping, a participatory mixed-methods approach, was used. Participants were parents or caregivers of a child with cancer, childhood cancer survivors, and clinical or nonclinical support personnel, fluent in English, Spanish, or Portuguese. A representative panel established a comprehensive list of relevant items. Participants individually sorted these items into concepts and then rated each item for impact using a four-point Likert scale. Multidimensional scaling and hierarchical cluster analysis identified concepts. Descriptive statistics were calculated for impact ratings.

RESULTS

One fourth (21/80) of participants were parents/caregivers or childhood cancer survivors. Participants worked in clinical (44/80), charity/volunteer (27/80), and other nonclinical (13/80) roles. Of the 41 represented countries, 78.0% (32) were low- and middle-income countries (LMICs). Conceptual themes spanned six distinct clusters: medical, nonmedical, assistance and support, treatment impact, family impact, and caregiver impact. These were distinct in composition compared with an existing framework for adult oncology. Caregiver impact (mean, 3.39) and treatment impact (mean, 3.29) were the highest rated clusters, and impact ratings were higher in LMICs compared with HICs.

CONCLUSION

We developed a framework for financial hardship in childhood cancer that reflects the voices of stakeholders, including parents and caregivers, from diverse global contexts. The findings lay a foundation for the development and validation of tools to systematically assess financial hardship in families of children with cancer and inform effective policies and interventions.

Perceived vulnerability related to health in cancer post-treated adolescent in Iran: a content analysis

BACKGROUND

The prevalence of cancer is increasing, which significantly impacts the health and various aspects of the lives of cancer-post-treated adolescents. Adolescents with cancer have many negative consequences, including increased vulnerability. Therefore, this study aimed to explore the perceived vulnerability of cancer-post-treated adolescents using a deep examination of experiences and perceptions of participants.

METHODS

This study was conducted on 18 participants, who were selected based on purposive sampling in 2023 using a qualitative method through a content analysis approach in Iran. A face-to-face and semi-structured individual interview was used to collect data. Inclusion criteria were children aged 11-19 years, with no history of diseases except cancer, at least one year passed since their last treatment and were aware of their disease. Inclusion criteria for other participants were Parents of childhood cancer survivors whose child is under 19 years old. Health care providers that had at least one year of experience working with and caring for pediatric cancer survivors. The research objective, participation principle, and interview recording were explained to the participants before the interview started. The criteria of credibility, dependability, confirmability and transferability were included to support the trustworthiness of data. The data was analyzed using the conventional qualitative content analysis method and MAXQDA10 software was used for data management.

RESULTS

The participants included 12 cancer-post-treated adolescents, two parents, two nurses, one doctor, and one cancer charity representative. The data analysis identified three categories: "Confusion in early adolescence", "Psychological turmoil of disease", and "Physical burden of the disease". Finally, the latent content was formulated in to a "Perceived vulnerability" overarching theme.

CONCLUSION

Identifying the patient's perceptions and beliefs is one of the current health problems to improve the quality of life and facilitate the optimal transition from adolescence to adulthood and adult care. Health professionals have an opportunity to address factors that increase survivors' sense of vulnerability to health problems by correcting knowledge gaps.

Prevalence, trends, and specialized palliative care utilization in Taiwanese children and young adults with life-limiting conditions between 2008 and 2017: a nationwide population-based study

BACKGROUND

Previous studies have shown a growing need for pediatric palliative care, but there is a lack of knowledge in many countries concerning prevalence of service use among children and young adults with life-limiting conditions. This study aimed to estimate (1) the annual prevalence of children and young adults with a life-limiting condition, and (2) their specialized palliative care and other healthcare utilization.

METHODS

Data from the Health and Welfare Data Science Center in Taiwan were used. All children and young adults aged 0-25 years recorded in inpatient or outpatient data, and infants aged < 1 year in death data with a life-limiting condition diagnostic code from 2008 to 2017 were recruited. Poisson regression was used to estimate the crude and adjusted relative risk of prevalence of life-limiting conditions with 95% confidence intervals, adjusted for age and sex, and to evaluate the trend in prevalence of each life-limiting diagnostic groups, in specialized palliative care and other service use.

RESULTS

Data contained 236,250 individuals with a life-limiting condition, of which oncological and congenital abnormalities were the most common. There was an annualized increase over 10 years in the prevalence of life-limiting conditions of 36.4%, from 45,311 cases (59.4 per 10,000 population) to 52,226 cases (81.0 per 10,000 population), with the highest prevalence in individuals aged 21-25 years. All diagnostic groups showed significant increases in prevalence (p < .001) with the exception of oncology, circulatory, and "other" group. Specialized palliative care services, including family consultation, shared care, home visits have increased in use over time (p < .001), while inpatient hospice has slightly decreased. The highest prevalence of healthcare use was for traditional Chinese medicine (237.1 per 1,000 population in 2017), but this decreased over time (p < .001).

CONCLUSIONS

Due to a growing trend towards multidisciplinary care, healthcare professionals and policymakers must engage and take action to expand specialized palliative care and integrate delivery of other healthcare services. Traditional Chinese medicine having a decreasing slope, yet still the highest prevalence of use, needs further attention.

Examining the involvement of guardians of children with acute lymphoblastic leukemia in Tanzania as public contributors to inform the design and conduct of the GuardiansCan project: A mixed-methods study protocol

BACKGROUND

Public contribution in research can lead to the design and conduct of more feasible and relevant research. However, our understanding of the acceptability and feasibility of public contribution and the evidence base regarding its impact in low- and middle-income countries (LMICs) is limited.

METHODS

In this study protocol, we describe a mixed-method examination of public contribution activities in the GuardiansCan project. The GuardiansCan project aims to respond to Tanzanian guardians' poor adherence to children's follow-up care after treatment for acute lymphoblastic leukemia (ALL) with the help of Mobile Health technology. We aim to: (1) involve guardians of children treated for ALL as Guardians Advisory Board (GAB) members in the managing and undertaking, analysis and interpretation, and dissemination phases of the GuardiansCan project; and (2) examine the acceptability, feasibility, and perceived impact of GAB members' contribution to the GuardiansCan project from the perspective of the GAB members and public contribution coordinators. We will recruit six to eight guardians of children treated for ALL to the GAB. We will hold workshops where GAB members contribute to all project phases. Using impact logs, we will record GAB workshop activities and the perceived impact of these activities. We will interview GAB members and public contribution coordinators 6 months after establishing the GAB, and at the end of each study within the project, to examine the acceptability, feasibility, and perceived impact of public contribution activities.

DISCUSSION

We expect GAB contribution to increase project quality and relevance, and inform how to best embed public contribution in research in LMICs.

Expanding the Global Capacity for Childhood Cancer Registration: The ChildGICR Masterclass

PURPOSE

One determinant of the paucity of data on childhood cancer in low- and middle-income countries is the lack of capacity to register these cases. Combining expertise of the Global Initiative for Cancer Registry Development (GICR) and St Jude Global, we developed a ChildGICR educational program to promote data production.

METHODS

We first conducted a needs assessment to identify priority educational topics. Then, we designed the ChildGICR Masterclass, in which individuals with the potential to lead pediatric cancer registration were supported to prepare standard educational material. The outcomes were evaluated using qualitative and quantitative measures.

RESULTS

On the basis of indications by 38 GICR collaborators, we identified seven topics relevant to childhood cancer: burden description, registration principles, tumor classification, tumor staging, data quality control, data analysis, and data use. The ChildGICR Masterclass was held online in 2021 over 12 weeks. The 22 nominated participants created presentations in working groups and during live sessions. They also designed future training courses tailored to the needs of their region. Nineteen participants viewed the course experience as excellent, and 20 would continue engagement in the ChildGICR training activities. The developed material was 89% useful according to the faculty of the three online end courses, taught to 88 participants in 16 countries in 2022 and 2023. Among the 75 responding participants, 72 agreed that the learning objectives were attained and 60 were keen to engage in childhood cancer registration activities.

CONCLUSION

The ChildGICR Masterclass participants laid the foundation for a network of trainers. Knowledge dissemination in childhood cancer registration is the first necessary step toward evidence-based cancer control. The ChildGICR Masterclass can serve as a model to design, plan, and implement educational programs for health care professionals.

Impact of a Regional Pediatric Hematology/Oncology Fellowship Program in Guatemala

PURPOSE

This study aimed to describe and assess the regional experience of a pediatric hematology/oncology fellowship program based in Guatemala.

METHODS

The Unidad Nacional de Oncología Pediátrica (UNOP) in Guatemala City, Guatemala, is the only hospital in Central America dedicated exclusively to childhood and adolescent cancer. To address the regional need for specialists, a fellowship program in pediatric hematology/oncology was launched in 2003. The UNOP fellowship program comprises 3 years of training. Although the program is based at UNOP, it also includes rotations locally and internationally to enhance clinical exposure. The curriculum is based on international standards to cover clinical expertise, research, professionalism, communication, and health advocacy. Trainees are selected according to country or facility-level need for pediatric hematologists/oncologists, with a plan for them to be hired immediately after completing their training.

RESULTS

Forty physicians from 10 countries in Latin America have completed training. In addition, there are currently 13 fellows from five countries in training. Of the graduates, 39 (98%) are now practicing in pediatric hematology/oncology in Latin America. Moreover, many of them have leadership positions within their institutions and participate in research, advocacy, and policy making. Graduates from the UNOP program contribute to institutions by providing care for an increasing number of patients with pediatric cancer. The UNOP program is the first pediatric hematology/oncology fellowship program in the world to be accredited by Accreditation Council for Graduate Medical Education-International, an international body accrediting clinical training programs.

CONCLUSION

The UNOP program has trained specialists to increase the available care for children with cancer in Latin America. This regional approach to specialist training can maximize resources and serve as a model for other programs and regions.

The experiences of children and adolescents with cancer returning to school: A qualitative meta-synthesis

BACKGROUND

Returning to school can be challenging for children and adolescents with cancer who have been absent for a long time. As there is little known about the return to school experience of children and adolescents with cancer, this meta-synthesis aimed to describe the experiences of children and adolescent cancer patients as they return to school.

METHODS

Seven English databases and three Chinese databases were searched from inception to March 14, 2023. The Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) was used to appraise study quality. Data were synthesized using the Thomas and Harden thematic and content analysis method.

RESULTS

Twelve qualitative studies met the inclusion criteria and were analyzed into meta-synthesis. Data synthesis led to constructing four analytical themes and twelve sub-themes. The four major themes constructed were:benefits to school re-entry, barriers to school re-entry, motivators to school re-entry and the adaptation process after returning to school.

CONCLUSION

Children and adolescents with cancer were willing to return to education and can adapt to school life over time. But they were faced with challenges, including physical, psychological, and social barriers. Appropriate measures need to be taken to reduce those barriers.

IMPLICATIONS TO PRACTICE

Findings can be used to inform future research and interventions to support a successful return to education for children and adolescents with cancer. Healthcare providers should address the needs of children and adolescents at different stages and actively work with schools, hospitals and families to help childhood cancer survivors successfully return to school.

Unification of Efforts to Improve Global Access to Cancer Therapeutics: Report From the 2022/2023 Access to Essential Cancer Medicines Stakeholder Summit

PURPOSE

There is an urgent need to improve access to cancer therapy globally. Several independent initiatives have been undertaken to improve access to cancer medicines, and additional new initiatives are in development. Improved sharing of experiences and increased collaboration are needed to achieve substantial improvements in global access to essential oncology medicines.

METHODS

The inaugural Access to Essential Cancer Medicines Stakeholder Meeting was organized by ASCO and convened at the June 2022 ASCO Annual Meeting in Chicago, IL, with two subsequent meetings, Union for International Cancer Control World Cancer Congress held in Geneva, Switzerland, in October 2022 and at the ASCO Annual Meeting in June of 2023. Invited stakeholders included representatives from cancer institutes, physicians, researchers, professional societies, the pharmaceutical industry, patient advocacy organizations, funders, cancer organizations and foundations, policy makers, and regulatory bodies. The session was moderated by ASCO. Past efforts and current and upcoming initiatives were initially discussed (2022), updates on progress were provided (2023), and broad agreement on resulting action steps was achieved with participants.

RESULTS

Summit participants recognized that while much work was ongoing to enhance access to cancer therapeutics globally, communication and synergy across projects and organizations could be enhanced by providing a platform for collaboration and shared expertise.

CONCLUSION

The summit resulted in new cross-stakeholder insights and planned collaboration addressing barriers to accessing cancer medications. Specific actions and timelines for implementation and reporting were established.

Short-term chemotherapy-related complications and undernutrition in children diagnosed with cancer at Korle Bu Teaching Hospital, Accra, Ghana: A prospective cohort study

Undernutrition in children with cancer is associated with complications during cancer therapy. The study objective was to determine the association between specific anthropometric parameters and short-term chemotherapy-related complications and mortality. This was a hospital-based, prospective cohort study of children, age ≤12 years, with a new cancer diagnosis at the Paediatric Oncology Unit, Korle Bu Teaching Hospital, Ghana. Socio-demographic information, cancer characteristics and anthropometric measurements were obtained at enrolment. Participants were followed up for twelve weeks from commencement of chemotherapy and selected treatment-related complications such as anaemia and thrombocytopenia requiring transfusions, prolonged neutropenia resulting in treatment delays, febrile neutropenia, mucositis and death were recorded. A total of 133 participants were recruited with a median age of 4.5 years. Eighty-one (60.9%) were diagnosed with solid tumours, 31 (23.3%) had leukaemias and 21 (15.8%) had lymphomas. Of the anthropometric parameters assessed, only arm anthropometry using upper arm muscle area (UAMA) and mid-upper arm circumference (MUAC) were associated with complications. Participants with wasting were more likely to develop anaemia and mucositis. However, the incidence of prolonged neutropenia was significantly higher among participants with average UAMA (p = 0.043) and low average UAMA (p = 0.049) compared to those with low UAMA. Risk of neutropenia was also significantly less among those with wasting by MUAC compared to those well-nourished (p = 0.045). Twenty-three participants (17.3%) died with a greater proportion (11/44; 25%) occurring in those who were wasted using MUAC. These findings underscore the need for nutritional surveillance at diagnosis and during chemotherapy, particularly where co-morbid disease is prevalent.

Increasing pediatric radiation oncology capacity in sub-saharan Africa using technology: a pilot of a pediatric radiation oncology virtual training course

BACKGROUND

The shortage of skilled healthcare professionals in pediatric oncology and the limited access to training programs remain significant challenges in Nigeria and sub-Saharan Africa. The the Pediatric Radiation Oncology (Virtual) Course, 'PedROC' project aims to contribute to improving pediatric cancer outcomes in Nigeria by increasing the capacity of radiation oncology professionals. To address the gap in access to pediatric radiation oncology professional development, the PedROC project was created, harnessing technology to improve radiation oncology training via a curriculum delivered through web-conferencing. This study aimed to evaluate the effectiveness of the PedROC pilot in enhancing the capacity, confidence, and skill of radiation oncologists in decision-making, prescribing, and treatment planning of radiotherapy for children diagnosed with cancer.

METHODS

A multidisciplinary faculty of specialists in radiation oncology, pediatric oncology, oncology nursing, radiation therapy technology, and medical physics collaborated to identify the key learning needs in pediatric radiation oncology in the country. The team collaborated to develop a comprehensive curriculum covering the most common pediatric cancers in sub-Saharan Africa for the training program. The training course was conducted over two days, delivering twenty-four half-hour sessions for a total of 12 h, from July 31 to August 01, 2021.

RESULTS

Analysis of pre and post - training surveys showed a significant increase in self-reported confidence measures across all domains among radiation oncologists. The program successfully improved participants' knowledge and confidence levels in managing common pediatric cancers using radiotherapy, particularly addressing radiotherapy-specific issues such as appropriate dose, target volume delineation, treatment planning, dose constraints, and plan evaluation.

CONCLUSION

The PedROC pilot showed the efficacy of this model in enhancing the capacity and confidence of radiation oncology professionals involved in the treatment of pediatric cancer. The findings indicate that technology holds significant potential to increase pediatric radiation oncology capacity in Africa, ensuring improved access to proper treatment and ultimately improving pediatric cancer outcomes.

Financial burden faced by breastfeeding mothers caring for children diagnosed with cancer in Ghana; an exploratory qualitative study

BACKGROUND

When children are diagnosed of cancer, parents face varied financial issues. Among some of the identifiable factors that cause financial challenges among breastfeeding mothers include the high cost of childhood cancer care. The high cost of childhood cancer care could impede the sustainability of access to prompt care. There is paucity of literature on the financial burdens faced by breastfeeding mothers with children diagnosed with cancer in Ghana. Therefore, this study sought to explore the financial burden faced by mothers with breastfeeding children diagnosed with cancer.

METHODS

The study employed qualitative exploratory descriptive design. One-on-one interviews were conducted among 13 mothers with breastfeeding children diagnosed of cancer. Permission was sought for data to be recorded, transcribed concurrently and inductive content analysis done.

RESULTS

Three main themes emerged after data analysis: High cost (sub-themes; expensive medications, laboratory investigation fees, and cost of mothers' feeding), Public support (sub-themes; appeal for funds, national health insurance scheme) and Self-financing (loans, personal savings). Most of the breastfeeding mothers narrated that high cost of childhood cancer care generated financial distress to them. They shared that the cost involved in purchasing their children's cancer medications, paying for laboratory investigations and feeding themselves to produce adequate breastmilk to feed their children were challenging. Some of the mothers self-financed the cost of their children's cancer care through loans and personal savings.

CONCLUSION

Government and other stakeholders should allocate annual budget and funds towards childhood cancer care to lessen the financial burden breastfeeding mothers caring for children with cancer experience.