Navigating the economic challenges in childhood cancer control in low- and middle-income countries: Insights from the CC-BRIDGE tool and the global initiative for childhood cancer

The increasing incidence of childhood cancer in low- and middle-income countries (LMICs) presents significant economic and logistical challenges, affecting health care provision and equitable treatment access. This editorial explores the economic barriers to pediatric oncology care in LMICs, highlighting resource scarcity, socioeconomic inequities, and health care complexities. It emphasizes the need for detailed cost analysis within health systems complicated by inadequate data and variable treatment protocols. Central to the discussion is the "Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity (CC-BRIDGE) Tool" from the manuscript by Nancy Bolous et al., who proposed an innovative method to estimate the cost of integrating childhood cancer services into National Cancer Control Plans. This tool aligns with the World Health Organization's Global Initiative for Childhood Cancer to enhance survival rates and advocate for universal health coverage in pediatric oncology. The CC-BRIDGE tool's methodological rigor provides a structured framework for cost analysis. Yet, it is recognized as an initial step requiring further enhancements for comprehensive economic forecasting and societal cost assessments. In conclusion, the editorial highlights the tool's critical role in incorporating childhood cancer care into national strategies in LMICs, contributing to the broader fight against cancer and advocating for comprehensive, equitable health care. It signifies a vital stride toward addressing pediatric oncology's economic challenges and supporting universal health coverage for childhood cancer care.

The Effect of COVID-19 on Oncology Care for Adolescents and Young Adults in Latin America

Children with cancer in low- and middle-income countries were disproportionately impacted by the COVID-19 pandemic, but little is known about how adolescents and young adults (AYAs) with cancer were affected. Sixty-seven physicians and nonphysician providers were interviewed about their experiences caring for AYAs with cancer in Latin America. Quotes related to the COVID-19 pandemic were identified and grouped into themes. Barriers from the COVID-19 pandemic included limited space, restrictions on travel, reduced funding, limited staff, limited services, and changes to treatment. However, improvements to care that arose from the COVID-19 pandemic included better access to distance learning and telemedicine.

Treatment of high-risk Hodgkin lymphoma with a modified Stanford V regimen in the AHOPCA: Substituting chemotherapy agents and hampered outcomes

BACKGROUND/OBJECTIVES

High-risk Hodgkin lymphoma (HRHL) in children is curable with combined modality therapy. The Association of Pediatric Hematology-Oncology of Central America (AHOPCA) is a consortium of cancer centers from Central America. In 2004, AHOPCA implemented a guideline with a short course of chemotherapy (mStanfordV), strict diagnostics, and radiation guidelines, aimed at reducing abandonment and improving outcomes.

METHODS

Newly diagnosed children less than 18 years of age with high-risk HL (Ann Arbor stages: IIB, IIIB, IV) from AHOPCA centers were staged with chest radiography and ultrasound or computed tomography. Therapy was a modified Stanford V (mStanfordV), substituting cyclophosphamide for mechlorethamine and involved field radiation.

RESULTS

Of 219 patients with HRHL, 181 patients were eligible and evaluable; 146 (81%) were boys, 22% being less than 6 years; 43 were stage IIB, 84 IIIB, and 54 IV. Thirty-one (17%) abandoned therapy, 28 (15%) progressed, 30 (17%) relapsed, and eight (4%) died of toxicity. Radiation guidelines were not followed. Five-year abandonment-sensitive event-free survival and overall survival (AS-EFS, AS-OS ± SE) for the cohort were 46% ± 4% and 56% ± 4%; 5-year AS-OS for stages IIB, IIIB, and IV was 76% ± 7%, 59% ± 7%, and 35% ± 7% (p = .0006).

CONCLUSION

Despite instituting a short treatment guideline, it did not improve the abandonment rate (17%) and did not achieve the reported outcomes of Stanford V. The cyclophosphamide dose used to replace merchlorethamine was inadequate. Despite strict guidelines, the radiation therapy application was inaccurate. Weekly chemotherapy may have adversely affected abandonment of therapy by increasing the burden of travel time. Based on these results, AHOPCA established a new abandonment strategy and a new guideline.

Standards for psychosocial care in pediatric cancer: adapted proposal for Latin American and Caribbean countries

Objective

To highlight the objectives, achievements, challenges, and next steps for the World Health Organization's Global Initiative for Childhood Cancer (GICC) framework, a project designed to improve psychosocial care (PSC) in pediatric cancer centers across Latin America and the Caribbean (LAC).

Methods

The project was launched in Peru, the first GICC focal country, in November 2020. The diagnosis phase included a survey and a semistructured interview with health professionals to assess PSC practices in institutions, and a needs assessment survey for caregivers. In the second phase, a strategic plan was developed to address the identified needs, including the adaptation of PSC standards, the establishment of multicenter working groups, the expansion of the proposal, and the development of materials.

Results

The study found that PSC was not being adequately provided in accordance with international standards. Six adapted standards were proposed and validated, and more than 50 regional health professionals participated in online activities to support the project. The implementation process is currently ongoing, with the establishment of five multidisciplinary working groups, one regional committee, and the production of 16 technical outputs.

Conclusion

This project represents a substantial step forward to improve PSC for pediatric patients with cancer and their families in LAC countries. The establishment of working groups and evidence-based interventions strengthen the proposal and its implementation. Development of health policies that include PSC according to standards is needed to achieve sustainable results in the quality of life of children with cancer and their families.

Collaborative effort to catalyze the implementation of the Global Initiative for Childhood Cancer in the Central American subregion

In Central America, childhood cancer is one of the leading causes of death. It is also a significant disease burden to health systems, with social and economic implications for families. The World Health Organization (WHO), the Executive Secretary of the Council of Ministers of Health of Central America and the Dominican Republic (SE-COMISCA), the Pan American Health Organization (PAHO), and St Jude Children's Research Hospital are working collaboratively to strengthen the health system's response to childhood cancer in Central America and the Dominican Republic. This collaboration's primary objective is to support the development of national pediatric cancer plans for each country in the subregion and improve overall survival rates and quality of care for children with cancer through a more comprehensive universal health coverage package. This collaborative effort has led to: (i) the development of childhood cancer national action plans; (ii) the launch of awareness and promotion campaigns; (iii) the design of childhood cancer educational material for children and their families; and (iv) a platform for professionals working in childhood cancer to share good practices and successful experiences. The countries of the subregion together with PAHO and St Jude Children's Research Hospital are working to develop standardized evidence-based clinical practice guidelines on childhood cancer for the region. This brief communication reports on this collaborative work.

Collaboration for success: the Global Initiative for Childhood Cancer in Latin America

The Global Initiative for Childhood Cancer (GICC) aims to increase the cure rate for children with cancer globally by improving healthcare access and quality. The Pan American Health Organization (PAHO), St. Jude Children's Research Hospital (St. Jude), and collaborators have joined efforts to improve outcomes of children with cancer in Latin America and the Caribbean (LAC) using the CureAll framework. In this article, we describe the process of developing regional resources aimed at accelerating the GICC implementation in LAC. In March 2021, PAHO formed regional working groups to develop core projects aligned with CureAll pillars and enablers. Seven working groups emerged from regional dialogues: early detection, nursing, psychosocial, nutrition, supportive care, treatment abandonment, and palliative care. PAHO arranged regular online meetings under the mentorship and support of St. Jude regional/transversal programs and international mentors. Between April and December 2021, 202 multidisciplinary experts attended 43 online meetings to promote the dialogue between stakeholders to improve childhood cancer outcomes. Fourteen technical outputs were produced: four regional snapshots, four technical documents, two virtual courses, one set of epidemiological country profiles, one educational content series for parents/caregivers, and two communication campaigns. The ongoing dialogue and commitment of PAHO, St. Jude, LAC working committees, and international collaborators are essential foundations to successfully accelerate GICC implementation. This is achievable through the development of materials of regional and global relevance. Further research and evaluation are needed to determine the impact of these strategies and resources on childhood cancer outcomes in LAC and other regions.

Regional collaboration for the development of national childhood cancer plans in Latin America and the Caribbean

This article aims to describe the activities conducted by the National Childhood Cancer Plan Working Group to support the development of national childhood cancer plans in Latin America and the Caribbean in the period 2019-2022, and to present the stage of plan development. The Working Group activities were supported by the Pan American Health Organization and St. Jude Children's Research Hospital, which is the World Health Organization (WHO) Collaborating Centre for Childhood Cancer. Year after year, the workshops and activities developed with the Working Group mobilized key stakeholders: pediatric oncologists, representatives of the Ministry of Health, foundations supporting childhood cancer initiatives, and hospital administrators. As of February 2023, one regional framework is in place, approved by the Council of Ministries of Health of Central America and the Dominican Republic, nine countries are currently implementing national plans or laws that include childhood cancer, and ten countries are writing new plans. The WHO three-step framework helped to guide the Working Group activities. All plans were supported by a situational analysis, which highlighted the importance of having systematized data for evidence-based policies. To increase implementation success, an accompanying budget and timeline help to ensure the adequate implementation of the interventions. More than anything, committed stakeholders remain the most fundamental element to successfully write and approve a national childhood cancer plan. This is an opportunity to share these countries' experience so the strategy can be adapted to support other countries developing a childhood cancer plan and extended to other public health areas.

Partnering to implement the Global Initiative for Childhood Cancer in the Americas: prioritizing systems strengthening

Working with PAHO/WHO to prioritize childhood cancer in the context of systems strengthening is central to St. Jude Children's Research Hospital (SJCRH)'s role as WHO Collaborating Centre for Childhood Cancer. This manuscript focuses on how SJCRH and PAHO/WHO have partnered to apply C5 (Country Collaboration for Childhood Cancer Control) to define and implement priority actions regionally, strengthening Ministry programs for childhood cancer, while implementing the Global Initiative for Childhood Cancer since 2018. Using C5, a tool developed by SJCRH, PAHO/WHO and SJCRH co-hosted regional/national workshops engaging authorities, clinicians and other stakeholders across 10 countries to map health systems needs and prioritize strategic activities (spanning Central America, Dominican Republic, Haiti, Brazil and Uruguay). SJCRH provided English/Spanish/Portuguese C5 versions/templates for analysis/prioritization exercises, and worked with PAHO/WHO and country teams to implement C5, analyze findings, and develop outputs. In an eight-country regional workshop, countries defined priorities within national/regional initiatives and ranked their value and political will, incorporating country-specific surveys and stakeholder dialogues. Each country prioritized one strategic activity for 2022-2023, exchanged insights via storytelling, and disseminated and applied results to inform country-specific and regional action plans. National workshops analyses have been incorporated into cancer control planning activities and collaborative work regionally. Implementation success factors include engaging actors beyond the clinic, enabling flexibility, and focusing on co-design with stakeholders. Joint implementation of C5 catalyzed prioritization and accelerated strategic activities to improve policies, capacity, and quality of care for children in the Americas, supporting Ministries to integrate childhood cancer interventions as part of systems strengthening.

Multinational Retrospective Central Pathology Review of Neuroblastoma: Lessons Learned to Establish a Regional Pathology Referral Center in Resource-Limited Settings

CONTEXT.—

Several countries of the Central America and Caribbean region have been sharing regional neuroblastoma (NB) treatment guidelines. However, there is no standardization in the diagnosis, subclassification, or tumor biology to aid in the risk stratification of these patients.

OBJECTIVE.—

To examine the histology and assess the accuracy of the local pathology reports; to evaluate the usefulness of manual MYCN immunohistochemistry (IHC); and to use NB as a model to identify the needs to establish a central pathology review (CPR) program in this region.

DESIGN.—

A retrospective CPR of specimens derived from patients with a diagnosis of NB and treated under the regional NB guidelines between 2012 and 2017 was conducted, allowing for a comparison between local diagnoses and the CPR diagnoses. Manual MYCN IHC was performed in the confirmed NB specimens and the results compared with known fluorescence in situ hybridization or automated IHC results, when available.

RESULTS.—

The 156 specimens reviewed included 460 blocks and 183 original slides. Neuroblastoma was confirmed in 138 samples (88.5%), but low concordance rates for Shimada classification (n = 39; 25.0%), mitotic-karyorrhectic index (n = 4; 2.5%), and International Neuroblastoma Pathology Classification (n = 18; 11.5%) were noted. Manual MYCN IHC performed on 120 specimens showed conclusive results in 89.2% (28 positive, 23.4%; 79 negative, 65.8%) and questionable results in 10.8% (n = 13).

CONCLUSIONS.—

This retrospective CPR highlights the need for a CPR program to serve this region, to ensure correct diagnosis and subclassification of NB, and to provide manual MYCN IHC-with reflexing to fluorescence in situ hybridization, if questionable. This approach can further regional collaboration, enhance test utilization, and ultimately improve patients' outcomes.

Paediatric relapsed acute leukaemia: curative intent chemotherapy improves quality of life

OBJECTIVES

Paediatric patients with leukaemia with relapse or induction failure have poor prognosis. Anticipated quality of life (QoL) is important in treatment decision making. The objective was to determine if curative intent at relapse or induction failure, when compared with palliative intent, was associated with child's physical health, pain or general fatigue and parents' QoL over time among patients with paediatric leukaemia in El Salvador.

METHODS

This was a prospective observational cohort study. Children 2-18 years with acute leukaemia at first relapse or induction failure were eligible. Assessments occurred every 2 months for up to 2 years using validated proxy report and self-report scales, where guardians were the primary respondents. Initial curative or palliative intent was categorised at enrolment by physicians. The impact of initial intent on QoL was assessed using linear mixed effects models and interaction between QoL and time.

RESULTS

Of the 60 families enrolled, initial treatment intent was curative in 31 (51.7%) and palliative in 29 (48.3%). During the 2-year observation period, 44 children died. Initial curative intent significantly improved child's physical health (estimate=8.4, 95% CI 5.1 to 11.6), pain (estimate=5.4, 95% CI 1.5 to 9.2) and fatigue (estimate=6.6, 95% CI 3.2 to 9.9) compared with palliative intent, but not parents' QoL (estimate=1.0, 95% CI -0.8 to 2.8).

CONCLUSIONS

Among paediatric patients with acute leukaemia at relapse or induction failure, initial curative intent treatment plan was associated with better physical health, pain and fatigue when compared with palliative intent. A curative approach may be a reasonable option for patients with acute leukaemia even when prognosis is poor.

Development of paediatric non-stage prognosticator guidelines for population-based cancer registries and updates to the 2014 Toronto Paediatric Cancer Stage Guidelines

Population-based cancer registries (PBCRs) generate measures of cancer incidence and survival that are essential for cancer surveillance, research, and cancer control strategies. In 2014, the Toronto Paediatric Cancer Stage Guidelines were developed to standardise how PBCRs collect data on the stage at diagnosis for childhood cancer cases. These guidelines have been implemented in multiple jurisdictions worldwide to facilitate international comparative studies of incidence and outcome. Robust stratification by risk also requires data on key non-stage prognosticators (NSPs). Key experts and stakeholders used a modified Delphi approach to establish principles guiding paediatric cancer NSP data collection. With the use of these principles, recommendations were made on which NSPs should be collected for the major malignancies in children. The 2014 Toronto Stage Guidelines were also reviewed and updated where necessary. Wide adoption of the resultant Paediatric NSP Guidelines and updated Toronto Stage Guidelines will enhance the harmonisation and use of childhood cancer data provided by PBCRs.

Sustainable care for children with cancer: a Lancet Oncology Commission

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Delayed Enucleation With Neoadjuvant Chemotherapy in Advanced Intraocular Unilateral Retinoblastoma: AHOPCA II, a Prospective, Multi-Institutional Protocol in Central America

PURPOSE

Treatment abandonment because of enucleation refusal is a limitation of improving outcomes for children with retinoblastoma in countries with limited resources. Furthermore, many children present with buphthalmos and a high risk of globe rupture during enucleation. To address these unique circumstances, the AHOPCA II protocol introduced neoadjuvant chemotherapy with delayed enucleation.

PATIENTS AND METHODS

Patients with advanced unilateral intraocular disease (International Retinoblastoma Staging System [IRSS] stage I) were considered for upfront enucleation. Those with diffuse invasion of the choroid, postlaminar optic nerve, and/or anterior chamber invasion received six cycles of adjuvant chemotherapy (vincristine, carboplatin, and etoposide). Patients with buphthalmos and those with a perceived risk for enucleation refusal and/or abandonment were given two to three cycles of chemotherapy before scheduled enucleation followed by adjuvant chemotherapy to complete six cycles, regardless of pathology.

RESULTS

A total of 161 patients had unilateral IRSS stage I disease; 102 underwent upfront enucleation, and 59 had delayed enucleation. The estimated 5-year abandonment-sensitive event-free and overall survival rates for the group were 0.81 ± 0.03 and 0.86 ± 0.03, respectively. The 5-year estimated abandonment-sensitive event-free survival rates for patients undergoing upfront and delayed enucleation were 0.89 ± 0.03 and 0.68 ± 0.06, respectively (P = .001). Compared with AHOPCA I, abandonment for patients with IRSS stage I retinoblastoma decreased from 16% to 4%.

CONCLUSION

AHOPCA describes the results of advanced intraocular retinoblastoma treated with neoadjuvant chemotherapy. In eyes with buphthalmos and patients with risk of abandonment, neoadjuvant chemotherapy can be effective when followed by enucleation and adjuvant chemotherapy. Our study suggests that this approach can save patients with buphthalmos from ocular rupture and might reduce refusal of enucleation and abandonment.

Political priority and pathways to scale-up of childhood cancer care in five nations

Background

Despite increasing global attention to non-communicable diseases (NCDs) and their incorporation into universal health coverage (UHC), the factors that determine whether and how NCDs are prioritized in national health agendas and integrated into health systems remain poorly understood. Childhood cancer is a leading non-communicable cause of death in children aged 0–14 years worldwide. We investigated the political, social, and economic factors that influence health system priority-setting on childhood cancer care in a range of low- and middle-income countries (LMIC).

Methods and findings

Based on in-depth qualitative case studies, we analyzed the determinants of priority-setting for childhood cancer care in El Salvador, Guatemala, Ghana, India, and the Philippines using a conceptual framework that considers four principal influences on political prioritization: political contexts, actor power, ideas, and issue characteristics. Data for the analysis derived from in-depth interviews (n = 68) with key informants involved in or impacted by childhood cancer policies and programs in participating countries, supplemented by published academic literature and available policy documents.

Political priority for childhood cancer varies widely across the countries studied and is most influenced by political context and actor power dynamics. Ghana has placed relatively little national priority on childhood cancer, largely due to competing priorities and a lack of cohesion among stakeholders. In both El Salvador and Guatemala, actor power has played a central role in generating national priority for childhood cancer, where well-organized and -resourced civil society organizations have disrupted legacies of fragmented governance and financing to create priority for childhood cancer care. In India, the role of a uniquely empowered private actor was instrumental in creating political priority and establishing sustained channels of financing for childhood cancer care. In the Philippines, the childhood cancer community has capitalized on a window of opportunity to expand access and reduce disparities in childhood cancer care through the political prioritization of UHC and NCDs in current health system reforms.

Conclusions

The importance of key health system actors in determining the relative political priority for childhood cancer in the countries studied points to actor power as a critical enabler of prioritization in other LMIC. Responsiveness to political contexts–in particular, rhetorical and policy priority placed on NCDs and UHC–will be crucial to efforts to place childhood cancer firmly on national health agendas. National governments must be convinced of the potential for foundational health system strengthening through attention to childhood cancer care, and the presence and capability of networked actors primed to amplify public sector investments and catalyze change on the ground.

Outcome of pediatric non-Hodgkin lymphoma in Central America: A report of the Association of Pediatric Hematology Oncology of Central America (AHOPCA)

BACKGROUND

Treating B-non-Hodgkin lymphoma (B-NHL) in lower-income countries is challenging because of imprecise diagnosis, the increased risk of fatal toxicity associated with advanced disease at presentation, and limited supportive care.

PROCEDURE

Central American patients with newly diagnosed stage I or II B-NHL received a modified Berlin-Frankfurt-Münster (BFM) regimen including a prephase (prednisone, cyclophosphamide) followed by A/B/A courses (A: cytarabine, dexamethasone, etoposide, ifosfamide, methotrexate, and intrathecal therapy; B: cyclophosphamide, dexamethasone, doxorubicin, methotrexate, and intrathecal therapy). Those with stage III or IV NHL received additional courses (B/A/B), intensified for stage IV disease by additional vincristine and methotrexate doses. Patients in poor condition received a second prephase treatment before their chemotherapy courses.

RESULTS

Between March 2004 and June 2016, of 405 patients with B-NHL, 386 (109 females) were eligible for treatment. Immunohistochemistry was performed in 177 cases (47.4%) and characterized the disease as mature B-cell lymphoma. Stage distribution was as follows: I/II, 31 (8.1%); III, 252 (65.3%); IV, 93 (24.1%); 10 (2.6%) not available. The 3-year overall survival was 70% for the whole group (86% for stages I/II, 75% for stage III, 58% for stage IV). Events included death during induction (34 patients, 8.8%), relapse/progression (46, 11.9%), death in remission (9, 2.3%), second malignancy (1, 0.26%), and death of unknown cause (1, 0.26%). Twenty-three (6%) patients abandoned or refused therapy.

CONCLUSIONS

Approximately 70% of children with B-NHL from Central America experienced long-term, disease-free survival with a modified BFM schedule. Toxic death and relapse/resistant disease were the main reasons for treatment failure.

The cost and cost-effectiveness of childhood cancer treatment in El Salvador, Central America: A report from the Childhood Cancer 2030 Network

BACKGROUND

Although previous studies have examined the cost of treating individual childhood cancers in low-income and middle-income countries, to the authors' knowledge none has examined the overall cost and cost-effectiveness of operating a childhood cancer treatment center. Herein, the authors examined the cost and sources of financing of a pediatric cancer unit in Hospital Nacional de Ninos Benjamin Bloom in El Salvador, and make estimates of cost-effectiveness.

METHODS

Administrative data regarding costs and volumes of inputs were obtained for 2016 for the pediatric cancer unit. Similar cost and volume data were obtained for shared medical services provided centrally (eg, blood bank). Costs of central nonmedical support services (eg, utilities) were obtained from hospital data and attributed by inpatient share. Administrative data also were used for sources of financing. Cost-effectiveness was estimated based on the number of new patients diagnosed annually and survival rates.

RESULTS

The pediatric cancer unit cost $5.2 million to operate in 2016 (treating 90 outpatients per day and experiencing 1385 inpatient stays per year). Approximately three-quarters of the cost (74.7%) was attributed to 4 items: personnel (21.6%), pathological diagnosis (11.5%), pharmacy (chemotherapy, supportive care medications, and nutrition; 31.8%), and blood products (9.8%). Funding sources included government (52.5%), charitable foundations (44.2%), and a social security contribution scheme (3.4%). Based on 181 new patients per year and a 5-year survival rate of 48.5%, the cost per disability-adjusted life-year averted was $1624, which is under the threshold considered to be very cost effective.

CONCLUSIONS

Treating childhood cancer in a specialized unit in low-income and middle-income countries can be done cost-effectively. Strong support from charitable foundations aids with affordability. Cancer 2018;124:391-7. © 2017 American Cancer Society.

Cost and Cost-Effectiveness of Childhood Cancer Treatment in El Salvador: A Collaborative Budget Model

Abstract 32

Background:

Cure rates for childhood cancer in El Salvador (ES) have increased from 5% in 1991 to 68% today as a result of national and international support. Approximately 200 new cases of pediatric cancer are diagnosed annually in ES—all are treated centrally at the National Children’s Hospital Benjamin Bloom. The cost of childhood cancer treatment in low- and middle-income countries (LMICs), such as ES, has not been well investigated. Such data are integral to inform national childhood cancer treatment plans. We undertook this work to determine the cost of operating a national childhood cancer treatment center in ES and to provide an analytic model framework for similar cost analyses in other LMICs.

Methods:

We conducted a cross-sectional study to evaluate the cost of childhood cancer treatment covered by a collaborative budget model in ES. We calculated costs on the basis of annual cases diagnosed and admitted to National Children’s Hospital Benjamin Bloom, and captured supportive expenses for families that are essential to reducing abandonment. Cost-effective analyses were performed and compared with traditional thresholds.

Results:

Initial estimates indicate an annual total operating budget of $5.3 million to treat 200 new cases annually. When combined with current survival outcomes, this represents a cost-effective model using WHO-CHOICE thresholds.

Conclusion:

Providing the first such comprehensive, institution-based estimate for the cost of treatment of childhood cancer in LMICs, we show that a childhood cancer treatment center represents a cost-effective intervention. This baseline information can be used to prioritize future treatments and interventions in ES. This methodology also allows similar studies to be conducted in other LMICs. Together, these data will inform a case for investment in global access to childhood cancer treatment.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Soad Fuentes-Alabi No relationship to disclose Roberto Franklin Vasquez No relationship to disclose Nickhill Bhakta No relationship to disclose Carlos Rodriguez-Galindo Honoraria: Novimmune A. Lindsay Frazier Consulting or Advisory Role: Decibel Therapeutics Rifat Atun No relationship to disclose Sumit Gupta No relationship to disclose Susan Horton No relationship to disclose

An Analysis of Treatment Failure in Wilms Tumor (WT): A Report from the Central American Association of Pediatric Hematology/Oncology (AHOPCA)

Abstract 57

Background:

Patients with WT in AHOPCA present late with large abdominal masses, in poor clinical condition. This analysis focuses on treatment failure.

Methods:

Between 2012 and 2015, 182 evaluable patients were diagnosed with unilateral WT. Patients were staged with abdominal ultrasound/computed tomography and thorax radiograph/CT. Therapy was adapted from National Wilms Tumor Study-5 except for patients with large abdominal masses and/or severe malnutrition who received preoperative doxorubicin, vincristine, actinomycin-D for 4 to 6 weeks. Treatment failure was defined as abandonment of therapy, recurrent/progressive disease (PD), and death: early (< 2 weeks from diagnosis) or toxic (> 2 weeks after diagnosis).

Results:

49% were male; 23% were <2 years (median age 3.5y). Stage distribution: I, 8; II, 21; III, 116; IV, 37 cases. For 123/181 (68%) preoperative therapy was warranted (volume 579cm3). Treatment failures were: recurrence/PD 28; abandonment 19; early death 3, and toxic death 2. 2/29 (7%) patients with stage I/II suffered recurrence/PD, 13/116 (11%) stage III, and 13/37 (35%) stage IV. Most failures were metastatic (68%). Abandonment-sensitive 3-years EFS was 68%±0.04% (SE) for the all stages, 77%±0.043% abandonment-censored, and abandonment-sensitive OS was 71%±0.05%.

Conclusion:

Multicenter protocol-driven therapy tailored to fit regional needs is feasible in patients with WT. Abandonment remains a challenge as do early and toxic deaths due to advanced disease presentations in fragile children. Compared to previous eras 2000-2004 (3-year EFS 50%±4.3% and 2005-2011 (3-year EFS 59%±3.1%) survivals continue to improve. This improvement reflects the engagement of the whole multidisciplinary team including surgery, radiation oncology, and pathology.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST:

No COIs from the authors.

Paediatric cancer stage in population-based cancer registries: the Toronto consensus principles and guidelines

Population-based cancer registries generate estimates of incidence and survival that are essential for cancer surveillance, research, and control strategies. Although data on cancer stage allow meaningful assessments of changes in cancer incidence and outcomes, stage is not recorded by most population-based cancer registries. The main method of staging adult cancers is the TNM classification. The criteria for staging paediatric cancers, however, vary by diagnosis, have evolved over time, and sometimes vary by cooperative trial group. Consistency in the collection of staging data has therefore been challenging for population-based cancer registries. We assembled key experts and stakeholders (oncologists, cancer registrars, epidemiologists) and used a modified Delphi approach to establish principles for paediatric cancer stage collection. In this Review, we make recommendations on which staging systems should be adopted by population-based cancer registries for the major childhood cancers, including adaptations for low-income countries. Wide adoption of these guidelines in registries will ease international comparative incidence and outcome studies.