1
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Chakumatha E, Khofi H, Landman L, Weijers J, Bailey S, Chagaluka G, Molyneux E, Israels T. Towards zero percent treatment abandonment of patients with common and curable childhood cancer types in Blantyre, Malawi. Pediatr Blood Cancer 2022; 69:e29899. [PMID: 35869892 DOI: 10.1002/pbc.29899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Treatment abandonment is a common cause of treatment failure in low-income countries (LIC). We implemented a comprehensive package of interventions aiming to enable all families to complete the treatment of their child. The objective of this study was to evaluate the impact of those interventions. PROCEDURE In this prospective and historically controlled study, we included all children younger than 16 years with a newly diagnosed common and curable cancer type (acute lymphoblastic leukaemia [ALL], Hodgkin disease, Wilms tumour, retinoblastoma and Burkitt lymphoma) admitted to the Queen Elizabeth Central Hospital in Blantyre, Malawi, between 1 June 1 2019 and 1 June 1 2020. Interventions to enable treatment completion included full funding of costs to the family (treatment, transport, accommodation and food in the hospital) and tracking of patients if they did not attend treatment appointments. The outcomes of patients were compared with those of a similar historical cohort. RESULTS The intervention cohort of 150 patients were compared to 264 historical control patients. Treatment abandonment decreased significantly from 19% (49/264) to 7% (10/150) (p < .001). The proportion of patients with Wilms tumour, retinoblastoma or ALL alive without evidence of disease at the end of treatment increased from 38% (57/149) to 53% (44/83) (p = .03). CONCLUSION A simple and relatively low-cost comprehensive intervention package with no costs for families, significantly decreased treatment abandonment. This strategy may increase survival of children with common and curable cancers in LIC, especially when coupled with improvements in access to treatment and quality of treatment, including supportive care.
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Affiliation(s)
- Eunice Chakumatha
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Harriet Khofi
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Lisa Landman
- Academy Outreach and Department of Solid Tumours, Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - Janna Weijers
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Malawi.,Academy Outreach and Department of Solid Tumours, Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - Simon Bailey
- Department of Paediatric Oncology, Sir James Spence Institute of Child Health, Royal Victoria Infirmary Queen, Newcastle, UK
| | - George Chagaluka
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth Molyneux
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Trijn Israels
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Malawi.,Academy Outreach and Department of Solid Tumours, Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
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2
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van Heerden J, Balagadde-Kambugu J, Angom R, Lusobya RC, Chantada G, Desjardins L, Fabian ID, Israels T, Paintsil V, Hessissen L, Diouf MN, Elayadi M, Turner SD, Kouya F, Geel JA. Evaluating the baseline survival outcomes of the "six Global Initiative for Childhood Cancer index cancers" in Africa. Pediatr Hematol Oncol 2022; 40:203-223. [PMID: 36369884 DOI: 10.1080/08880018.2022.2140860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Limited survival data for the six Global Initiative for Childhood Cancer (GICC) priority cancers are available in Africa. Management of pediatric malignancies in Africa is challenging due to lack of resources, setting-specific comorbidities, high rates of late presentation and treatment abandonment. Reporting of outcome data is problematic due to the lack of registries. With the aim of evaluating the feasibility of baseline outcomes for the six index cancers, we present a descriptive analysis of respective survival rates in Africa. The survival rates were between 18% (lower middle-income countries) to 82.3% (upper middle-income countries) for acute lymphoblastic leukemia, between 26.9% (low-income countries) to 77.9% (upper middle-income countries) for nephroblastoma, between 23% (low-income countries) to 100% (upper middle-income countries), for retinoblastoma, 45% (low-income countries) to 95% (upper middle-income countries) for Hodgkin lymphoma and 28% (low-income countries) to 76% (upper middle-income countries) for Burkitt lymphoma. Solutions to improve survival rates and reported outcomes include establishing and funding sustainable registries, training and to actively include all countries in consortia from different African regions.HighlightsContinental differences in childhood cancer management such lack of resources, setting-specific comorbidities, high rates of late presentation and treatment abandonment, present challenges to the achievement of Global Initiative for Childhood Cancer goals.The available data registries do not adequately inform on the true incidences and outcomes of childhood cancers in Africa.The pathophysiology of some childhood cancers in Africa are associated with high-risk prognostic factors.Outcomes can be improved by greater regional collaboration to manage childhood cancer based on local resources and tumor characteristics.Some individual countries have reached the Global Initiative for Childhood Cancer goals for single cancers and it should be possible for more African countries to follow suit.
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Affiliation(s)
- Jaques van Heerden
- Pediatric Hematology and Oncology, Department of Pediatrics, Antwerp University Hospital, Antwerp, Belgium.,Pediatric hematology and Oncology, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa.,Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | | | - Racheal Angom
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Rebecca Claire Lusobya
- Department of Ophthalmology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Guillermo Chantada
- Department of Pediatric Oncology, Hospital Sant Joan de Deu, Barcelona, Spain
| | | | - Ido Didi Fabian
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Tel-Aviv, Israel.,International Center for Eye Health London School of Hygiene and Tropical Medicine, London, UK
| | - Trijn Israels
- Department of Pediatrics, Queen Elizabeth Central Hospital, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Vivian Paintsil
- Department of Child Health, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Laila Hessissen
- Pediatric Hematology and Oncology Center, University Mohammed V Rabat, Rabat, Morocco
| | | | - Moatasem Elayadi
- Department of Pediatric Oncology, National Cancer Institute, Egypt & Children Cancer Hospital of Egypt (CCHE-57357), Cairo University, Giza, Egypt
| | | | - Francine Kouya
- Department of Pediatric Oncology, Cameroon Baptist Convention Hospitals in Mutengene, Mbingo and Banso, Mutengene, Cameroon
| | - Jennifer A Geel
- Division of Pediatric Hematology-Oncology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Witwatersrand, South Africa
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3
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Rahiman EA, Bakhshi S, Deepam Pushpam, Ramamoorthy J, Das A, Ghara N, Kalra M, Kapoor G, Meena JP, Siddaigarhi S, Thulkar S, Sharma MC, Srinivasan R, Trehan A. Outcome and prognostic factors in childhood B non-Hodgkin lymphoma from India: Report by the Indian Pediatric Oncology Group (InPOG-NHL-16-01 study). Pediatr Hematol Oncol 2022; 39:391-405. [PMID: 34978257 DOI: 10.1080/08880018.2021.2002485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The literature on B-non-Hodgkin lymphoma (NHL) in India is restricted to individual hospital data. The study aimed to evaluate the epidemiology and outcome of B-NHL in our country. One hundred and ninety-one patients of B-NHL from 10 centers diagnosed between 2013 and 2016 were analyzed retrospectively. B/T lymphoblastic lymphoma and patients with inadequate data were excluded. The median age was 88 months (IQR: 56, 144) with an M:F ratio of 5.6:1. Undernourishment and stunting were seen in 36.5% and 22%. Primary site was abdomen in 66.5%. Hypoalbuminemia was noted in 82/170 (48.2%). Histological subtypes: Burkitt lymphoma (BL): 69.6%, Burkitt-like: 10.4%, and diffuse large B cell lymphoma (DLBCL): 13.6%, unclassified and others (6.4%). Stage distribution: I/II, 33 (17.3%), III, 114 (59.7%), and IV, 44 (23%). One-eighty-six patients took treatment. Protocols used were LMB and BFM in 160/186 (86%). At a median follow-up of 21.34 (IQR: 4.34, 36.57) months, the disease-free-survival (DFS) was 74.4% and event-free-survival (EFS) was 60.7%. Treatment-related mortality (TRM), relapse/progression and abandonment were 14.3%, 14.5%, and 8.4%, respectively. Bone marrow positivity, stage IV disease, and lactate dehydrogenase (LDH) > 2,000 U/l predicted inferior EFS. Stage IV disease, LDH > 2,000 U/l, bone marrow positivity, tumor lysis syndrome and low albumin predicted TRM; LDH retained significance on multivariate analysis for EFS and TRM [OR: 4.54, 95% CI: 1.14-20, p 0.03; OR 20, 95%CI: 1.69-250, p 0.017]. BL was the main histological subtype. High TRM and relapse/progression are hampering survival. An LDH > 2,000 U/l was adversely prognostic. These data demonstrate a need to develop a national protocol that balances toxicity and potential for cure.
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Affiliation(s)
- Emine A Rahiman
- Pediatric Hematology-Oncology Unit and Cytology Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Bakhshi
- Rotary Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Deepam Pushpam
- Rotary Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | | | | - Jagdish Prasad Meena
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sanjay Thulkar
- Rotary Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Meher Chand Sharma
- Rotary Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| | - Radhika Srinivasan
- Pediatric Hematology-Oncology Unit and Cytology Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Pediatric Hematology-Oncology Unit and Cytology Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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4
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Afungchwi GM, Kruger M, Kouya F, Tih P, McCormick P, Pondy-Ongotsoyi AH, Hesseling PB. Two decades of childhood cancer care in Cameroon: 2000-2020. Pediatr Blood Cancer 2021; 68:e28997. [PMID: 33719184 DOI: 10.1002/pbc.28997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Before the year 2000, there was no dedicated childhood cancer service in Cameroon. The aim of this study was to investigate the progress made with pediatric oncology care in Cameroon from 2000 to 2020. METHOD A literature search was conducted for published articles on childhood cancer in Cameroon and relevant documents, and conference abstracts were reviewed. The articles were analyzed under the themes: awareness, diagnosis, epidemiology, treatment, outcome, advocacy, partnerships, traditional and complementary medicine, palliative care, and capacity building. RESULTS Low awareness on childhood cancer was addressed with education activities targeting the general population and health care professionals. Cancer diagnosis was achieved with cytology, histology, and simple imaging. Management for common and curable cancers was implemented with use of modified treatment regimens for low- and middle-income settings. Nutritional support was shown to mitigate the effects of malnutrition on treatment toxicity, and support was provided for transportation and accommodation. There was good collaboration between the pediatric oncology professionals nationally and twinning with international partners. Capacity building activities led to the availability of three pediatric oncologists and pediatric oncology-trained nurses. Advocacy nationally led to the support of the Ministry of Health with pediatric oncology-specific priority actions in the latest national cancer control plan. CONCLUSION Childhood cancer should receive the necessary attention of health care policymakers in Cameroon. With continued commitment of government, nongovernmental organizations, charities, childhood cancer specialists, patient and parent groups, there should be an improved future for children with cancer in Cameroon.
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Affiliation(s)
- Glenn Mbah Afungchwi
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon.,Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mariana Kruger
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Francine Kouya
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - Pius Tih
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | | | - Angele-Hermine Pondy-Ongotsoyi
- Pediatric Hematology/Oncology, Mother and Child Center, Chantal Biya Foundation, Yaounde, Cameroon.,Department of Pediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Peter B Hesseling
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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5
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Five decades of low intensity and low survival: adapting intensified regimens to cure pediatric Burkitt lymphoma in Africa. Blood Adv 2021; 4:4007-4019. [PMID: 32841337 DOI: 10.1182/bloodadvances.2020002178] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Long-term cure of childhood Burkitt lymphoma (BL) in sub-Saharan Africa after treatment with single-agent cyclophosphamide has been documented for more than half of a century. Contemporary cure rates for the highest-risk patients with BL in high-income countries exceed 90% using intensive multiagent chemotherapy. By contrast, the majority of African children with BL still die. Data spanning 5 decades in Africa have repeatedly shown that the children most likely to achieve cure with limited cyclophosphamide regimens are those with lower-stage disease isolated to the jaw. Attempts to intensify the cyclophosphamide monotherapy backbone with the addition of vincristine, low-dose methotrexate, prednisone, doxorubicin, and/or low-dose cytarabine have not yielded significant improvement. High-dose methotrexate is a critical component in the treatment of childhood BL worldwide. Although initial efforts in Africa to incorporate high-dose methotrexate resulted in high treatment-related mortality, more recent collaborative experiences from North and West Africa, as well as Central America, demonstrate that it can be administered safely and effectively, despite limitations in supportive care resources. Recognizing the unacceptable disparity in curative outcomes for BL between the United States/Europe and equatorial Africa, there is a critical need to safely adapt contemporary treatment regimens to optimize curative outcomes amid the resource limitations in regions where BL is endemic. Here, we critically review reports of BL treatment outcomes from low- and middle-income countries, in addition to data from high-income countries that predated modern intensified regimens, to identify potential strategies to improve the therapeutic approach for children suffering from BL in sub-Saharan Africa.
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6
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Della Rocca AM, Leonart LP, Ferreira VL, Tonin FS, Steffenello-Durigon G, Del Moral JAG, Fernandez-Llimos F, Pontarolo R. Chemotherapy Treatments for Burkitt Lymphoma: Systematic Review of Interventional Studies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:514-525. [PMID: 33947633 DOI: 10.1016/j.clml.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/16/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Burkitt lymphoma (BL) is an aggressive hematologic cancer. This study synthetized the evidence about the efficacy and safety of chemotherapy treatments used in patients with BL using the World Health Organization classification. MATERIALS AND METHODS A systematic review of interventional studies was performed. A search was carried out in PubMed, Scopus, and Web of Science, with additional manual and gray literature searches. The methodological quality of articles was assessed with the Newcastle-Ottawa scale. RESULTS We identified 1358 studies; 9 nonrandomized studies satisfied the eligibility criteria (n = 544 patients). The BL epidemiologic variants were sporadic BL (44.5%), endemic BL (47.2%), and immunodeficiency-associated BL (8.3%). Regarding chemotherapy protocols, 4 groups were identified: based on CODOX-M/IVAC (n = 4), EPOCH (n = 1), BFM (n = 1), and simplified treatment schemes used in African countries (n = 3). Most studies had moderate quality. Empirically and qualitatively, the best options for adults with sporadic BL were 'DA-EPOCH-R' (7-year overall survival [OS], 100%; 95% confidence interval [CI], 82-100), 'HDR + LD into CODOX-M/IVAC' (2-year OS, 84%), and 'RD-CODOX-M/IVAC' (4-year progression-free survival, 92%; 95% CI, 77-100); in pediatric patients, the 'BFM-NHL-90-like' showed promising results (3-year OS, 90%). For immunodeficiency-associated BL, the 'SC-EPOCH-RR' demonstrated a good therapeutic profile (6-year OS, 90%; 95% CI, 60-98). The 'Malawi 2012-2014' (1-year OS, 73%; 95% CI, 61-85) could be the treatment choice in endemic BL (African countries). The main adverse events were hematologic. CONCLUSION Selecting chemotherapy protocols for BL should be grounded in its epidemiologic variants. Further studies with greater methodological quality are needed to strengthen the evidence.
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Affiliation(s)
- Ana M Della Rocca
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Letícia P Leonart
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Vinicius L Ferreira
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil
| | - Giovanna Steffenello-Durigon
- Hematology Service, University Hospital Professor Polydoro Ernani de São Thiago, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Joanita A G Del Moral
- Hematology Service, University Hospital Professor Polydoro Ernani de São Thiago, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Fernando Fernandez-Llimos
- Center for Health Technology and Services Research (CINTESIS), Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.
| | - Roberto Pontarolo
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, PR, Brazil; Department of Pharmacy, Federal University of Paraná, Curitiba, PR, Brazil.
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7
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Chakumatha E, Weijers J, Banda K, Bailey S, Molyneux E, Chagaluka G, Israels T. Outcome at the end of treatment of patients with common and curable childhood cancer types in Blantyre, Malawi. Pediatr Blood Cancer 2020; 67:e28322. [PMID: 32391955 DOI: 10.1002/pbc.28322] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND The WHO Global Initiative for Childhood Cancer aims to increase survival to at least 60% for all children with cancer globally, with initial focus on six common curable cancer types. Frequent causes of treatment failure in low income countries (LICs) are treatment abandonment and death during treatment. Here, we report on the outcome at the end of treatment of patients with newly diagnosed common and curable cancer types, admitted in the Queen Elizabeth Central Hospital, Blantyre, Malawi. PROCEDURE Outcome at end of treatment was documented and analyzed retrospectively for all children with a working diagnosis of a common and curable cancer type (ALL, Hodgkin disease, Wilms tumor, retinoblastoma, and Burkitt lymphoma) admitted over a 2-year period. Patients with a misdiagnosis were excluded. Outcomes were categorized as alive without evidence of disease, treatment abandonment, death during treatment, or persistent disease. RESULTS We included 264 patients. Seven patients with a misdiagnosis were excluded. At the end of treatment, 53% (139 of 264) of patients were alive without evidence of disease, 19% (49 of 264) had abandoned treatment, 23% (61 of 264) had died during treatment, and 6% (15 of 264) had persistent disease. CONCLUSION Survival of children with common and curable cancers is (significantly) below 50%. Almost half (42%) of the patients either abandoned treatment or died during treatment. Strategies to enable parents to complete treatment of their child and improved supportive care are needed. Such interventions may need to be given priority to improve the currently poor survival.
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Affiliation(s)
| | - Janna Weijers
- Department of Paediatrics, College of Medicine, Blantyre, Malawi.,Academy Outreach and Department of Solid Tumours, Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - Kondwani Banda
- Department of Paediatrics, College of Medicine, Blantyre, Malawi
| | - Simon Bailey
- Department of Paediatric Oncology, Sir James Spence Institute of Child Health, Royal Victoria Infirmary Queen, Newcastle, UK
| | | | - George Chagaluka
- Department of Paediatrics, College of Medicine, Blantyre, Malawi
| | - Trijn Israels
- Academy Outreach and Department of Solid Tumours, Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
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8
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McGoldrick SM, Mutyaba I, Adams SV, Larsen A, Krantz EM, Namirembe C, Mooka P, Nabakooza S, Ndagire M, Mubiru K, Nabwana M, Nankinga R, Gerdts S, Gordon-Maclean C, Geriga F, Omoding A, Sessle E, Kambugu J, Uldrick TS, Orem J, Casper C. Survival of children with endemic Burkitt lymphoma in a prospective clinical care project in Uganda. Pediatr Blood Cancer 2019; 66:e27813. [PMID: 31157502 DOI: 10.1002/pbc.27813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 04/10/2019] [Accepted: 04/26/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE "Endemic" Burkitt lymphoma (BL) is a common childhood cancer in Africa. Social and treatment factors may contribute to poor survival. With the aim of improving BL outcomes in Uganda, we undertook a comprehensive project (BL Project) that provided diagnostic support, access to standard chemotherapy, nutritional evaluations, and case management. We evaluated survival of children with BL in the context of the project. PATIENTS AND METHODS Patients followed by the BL Project who consented to research were enrolled in this study. Children with a pathology diagnosis consistent with BL were eligible. Data were collected prospectively. First-line chemotherapy generally consisted of six cycles of cyclophosphamide, vincristine, low-dose methotrexate (COM). We used Kaplan-Meier and Cox regression analyses to evaluate factors associated with overall survival (OS). RESULTS Between July 2012 and June 2017, 341 patients with suspected BL presented to the BL Project. One hundred eighty patients with a pathology-based diagnosis were included in this study. The median age was seven years (interquartile range, 5-9), 74% lived ≥100 km from the Uganda Cancer Institute, 61% had late-stage disease, 84% had ECOG performance status < 3, 63% reported B-symptoms, and 22% showed neurologic symptoms. Fewer than 10% abandoned therapy. The four-year OS rate was 44% (95% CI, 36%-53%). In a multivariate model, ECOG status was significantly associated with mortality. CONCLUSION The BL Project reduced effects of lacking supportive care and oncology resources, and allowed patients from Uganda to receive curative intent therapy with minimal loss to follow-up. Nonetheless, OS remains unacceptably low. Improved therapeutic approaches to endemic BL are urgently needed in Africa.
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Affiliation(s)
| | | | - Scott V Adams
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anna Larsen
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Peter Mooka
- Hutchinson Centre Research Institute, Kampala, Uganda
| | | | | | - Kelvin Mubiru
- Hutchinson Centre Research Institute, Kampala, Uganda
| | | | - Rose Nankinga
- Hutchinson Centre Research Institute, Kampala, Uganda
| | - Sarah Gerdts
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | | | | | - Corey Casper
- Departments of Medicine and Global Health, Infectious Disease Research Institute and the University of Washington, Seattle, Washington
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9
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Zhou P, Blain AE, Newman AM, Zaka M, Chagaluka G, Adlar FR, Offor UT, Broadbent C, Chaytor L, Whitehead A, Hall A, O'Connor H, Van Noorden S, Lampert I, Bailey S, Molyneux E, Bacon CM, Bomken S, Rand V. Sporadic and endemic Burkitt lymphoma have frequent FOXO1 mutations but distinct hotspots in the AKT recognition motif. Blood Adv 2019; 3:2118-2127. [PMID: 31300419 PMCID: PMC6650741 DOI: 10.1182/bloodadvances.2018029546] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/14/2019] [Indexed: 12/22/2022] Open
Abstract
FOXO1 has an oncogenic role in adult germinal center-derived lymphomas, in which mutations, predominately within the AKT recognition motif, cause nuclear retention of FOXO1, resulting in increased cell proliferation. To determine the prevalence and distribution of FOXO1 mutations in pediatric Burkitt lymphoma (BL), we sequenced a large number of sporadic and endemic BL patient samples. We report a high frequency of FOXO1 mutations in both sporadic and endemic BL at diagnosis, occurring in 23/78 (29%) and 48/89 (54%) samples, respectively, as well as 8/16 (50%) cases at relapse. Mutations of T24 were the most common in sporadic BL but were rare in endemic cases, in which mutations of residue S22, also within the AKT recognition motif, were the most frequent. FOXO1 mutations were almost always present in the major tumor cell clone but were not associated with outcome. Analysis of other recurrent mutations reported in BL revealed that FOXO1 mutations were associated with mutations of DDX3X and ARID1A, but not MYC, TCF3/ID3, or members of the phosphatidylinositol 3-kinase signaling pathway. We further show common nuclear retention of the FOXO1 protein, irrespective of mutation status, suggesting alternative unknown mechanisms for maintaining FOXO1 transcriptional activity in BL. CRISPR/Cas9 knockout of FOXO1 in an endemic cell line produced a significant decrease in cell proliferation, supporting an oncogenic role for FOXO1 in endemic BL. Thus, FOXO1 is frequently mutated in both sporadic and endemic BL and may offer a potential therapeutic target for pediatric BL patients worldwide.
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Affiliation(s)
- Peixun Zhou
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alex E Blain
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alexander M Newman
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Masood Zaka
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - George Chagaluka
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Filbert R Adlar
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ugonna T Offor
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Paediatric and Adolescent Haematology and Oncology, The Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Casey Broadbent
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lewis Chaytor
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Amber Whitehead
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Amy Hall
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hettie O'Connor
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Susan Van Noorden
- Department of Histopathology, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Irvin Lampert
- Department of Histopathology, West Middlesex University Hospital, Isleworth, United Kingdom; and
| | - Simon Bailey
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Paediatric and Adolescent Haematology and Oncology, The Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Chris M Bacon
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Simon Bomken
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Paediatric and Adolescent Haematology and Oncology, The Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Vikki Rand
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
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10
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Hesseling PB, Tamannai M, Ladas E, Afungchwi G, Katayi E, Kouya F. Burkitt lymphoma – Nutritional support during induction treatment: Effect on anthropometric parameters and morbidity of treatment. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2018. [DOI: 10.4102/sajo.v2i0.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Malnutrition is common in children diagnosed with cancer in Africa, and it adds to the morbidity and mortality of treatment. Nutritional support is known to reduce morbidity and mortality of treatment.Aim: The aim of this study was to record changes in anthropometric parameters, morbidity and mortality in patients admitted with Burkitt lymphoma (BL) whose diet was supplemented with protein, vitamins and minerals during induction chemotherapy.Methods: Seventy consecutive newly diagnosed BL patients were enrolled. The diet was supplemented with a daily egg, 200 mL F-75 formula and vitamins. Guardians received 3 cups of dry rice and $1 daily to buy and prepare meals for the patient and themselves whilst in the hospital. Height, weight, triceps skinfold (TSF) and mid-upper arm circumference (MUAC) were recorded on days 1 and 28. Co-morbidities at diagnosis were treated, and neutropenia and febrile episodes managed with a standard protocol. Two patients who died within 24 h after admission were excluded from the anthropometric analyses.Results: The mean age was 8 (range 2–16) years and the male:female ratio was 42:28. The St Jude stage distribution was as follows: Stage I = 6%, II = 4%, III = 69%, IV = 21%. Weight for age was < 10th centile at diagnosis in 18% (but influenced by tumour mass). Weight was unchanged or increased by ≥ 5% in 66% of patients on Day 28. The TSF was < 3rd centile in 47% of patients and increased by ≥ 0.5 cm in 57%. The MUAC was < 3rd centile in 16% of patients at diagnosis and in 10% of patients on Day 28. Febrile episodes in 60% and neutropenia in 18% of patients were successfully treated. Two patients died from presumed renal failure. The overall death rate (including the two deaths within 24 h after admission before chemotherapy was started) was 5.5% (n = 4).Conclusion: The TSF improved in the majority and the MUAC improved in some patients. Febrile neutropenia and febrile episodes could be successfully managed. The death rate during induction was lower than in our previously published results with the same chemotherapy protocol. Dietary supplementation should be a standard component of treatment in paediatric patients with cancer.
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11
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How I treat Burkitt lymphoma in children, adolescents, and young adults in sub-Saharan Africa. Blood 2018; 132:254-263. [PMID: 29769263 DOI: 10.1182/blood-2018-04-844472] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022] Open
Abstract
Burkitt lymphoma (BL) is the most common pediatric cancer in sub-Saharan Africa (SSA), and also occurs frequently among adolescents and young adults (AYAs), often associated with HIV. Treating BL in SSA poses particular challenges. Although highly effective, high-intensity cytotoxic treatments used in resource-rich settings are usually not feasible, and lower-intensity continuous infusion approaches are impractical. In this article, based on evidence from the region, we review management strategies for SSA focused on diagnosis and use of prephase and definitive treatment. Additionally, potentially better approaches for risk stratification and individualized therapy are elaborated. Compared with historical very low-intensity approaches, the relative safety, feasibility, and outcomes of regimens incorporating anthracyclines and/or high-dose systemic methotrexate for this population are discussed, along with requirements to administer such regimens safely. Finally, research priorities for BL in SSA are outlined including novel therapies, to reduce the unacceptable gap in outcomes for patients in SSA vs high-income countries (HICs). Sustained commitment to incremental advances and innovation, as in cooperative pediatric oncology groups in HICs, is required to transform care and outcomes for BL in SSA through international collaboration.
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12
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Molyneux E, Scanlan T, Chagaluka G, Renner L. Haematological cancers in African children: progress and challenges. Br J Haematol 2017; 177:971-978. [PMID: 28599352 DOI: 10.1111/bjh.14617] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cancer is increasingly important in low and middle-income settings where infectious diseases are declining. Childhood cancers treated in well-resourced centres have excellent outcomes with more than 80% survival. This success is not reflected in low-income settings where challenges involve every step on the care pathway. Access to diagnosis, delayed presentation, advanced disease, co-morbidities and underlying malnutrition make treatment difficult. Treatments are costly for impoverished families. Yet, the common haematological malignancies (Burkitt lymphoma, Hodgkin lymphoma, non Hodgkin lymphoma) are relatively easy to diagnose and, when managed with simple chemotherapy protocols, give limited but good results. As funding becomes available for cancer research we must ensure that the care and cure of these children is top of the agenda. There is already evidence of improved outcomes in middle-income countries. For others there is a long journey ahead.
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Affiliation(s)
| | | | | | - Lorna Renner
- University of Ghana School of Medicine and Dentistry, Accra, Ghana
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13
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Westmoreland KD, El-Mallawany NK, Kazembe P, Stanley CC, Gopal S. Dissecting heterogeneous outcomes for paediatric Burkitt lymphoma in Malawi after anthracycline-based treatment. Br J Haematol 2017; 181:853-854. [PMID: 28714257 DOI: 10.1111/bjh.14716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | | | - Peter Kazembe
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | | | - Satish Gopal
- UNC Project-Malawi, Lilongwe, Malawi.,University of North Carolina, Chapel Hill, NC, USA.,University of Malawi College of Medicine, Blantyre, Malawi
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14
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Abstract
Satish Gopal discusses the challenges of deliverable cancer care and cancer trials in sub-Saharan Africa as well as a potential framework for overcoming these challenges.
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Affiliation(s)
- Satish Gopal
- Malawi Cancer Consortium, Lilongwe, Malawi
- UNC Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- University of Malawi College of Medicine, Blantyre, Malawi
- * E-mail:
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