The Union for International Cancer Control estimates that 175,000
children are diagnosed with cancer every year and 90,000 will die of their
Most childhood cancers are curable, but money plays a huge role. Roughly
80% of children in resource-rich areas will survive while 80% of children in
resource-poor settings will die, according to the International Society of
Paediatric Oncology and the International Confederation of Childhood Cancer
World Health Statistics 2011 — the World Health Organization’s
annual compilation of health-related data for its 193 member states —
paints a bleak picture. Upper middle- and high-income countries have 10 to 14
times as many physicians per 10,000 residents. High-income countries have 59
hospital beds per 10,000 residents vs. 36 in upper middle-income nations, 22 in
lower middle-income countries and 13 in low-income nations.
Skiles, MD, has traveled to Kenya as part of an exchange program with Moi
University School of Medicine for the past 7 years.
Photo courtesy of Indiana University
Health reprinted with permission.
As a percentage of gross domestic product, high-income countries spent
11.1% on health care in 2008, the most recent statistics available. In
comparison, low-income nations spent 5.4%.
Survival rates reflect that disparity. Only 5% of childhood cancers
diagnosed in Africa are cured vs. 80% in the rest of the world, according to
AfrOx, a nonprofit organization that helps African countries implement cancer
prevention and control programs.
Seventy-five percent of patients in Africa have advanced cancer at
diagnosis, David J. Kerr, MD, PhD, Rhodes professor of clinical
pharmacology and cancer therapeutics at the University of Oxford, United
Kingdom, and past-president of the European Society for Medical Oncology
(ESMO), said during a presentation at the 2011 ASCO Annual Meeting.
“The problem I have when I go into the clinic is that we see
advanced disease,” Kerr said. “I’m seeing medieval-type cancers
that I haven’t seen in a 30-year career as a medical oncologist.”
Although Western institutions cannot erase the lack of resources in the
developing world, several are experimenting with ways to fill in the gap. Some
provide funding. Others are going a step further by relocating their own
physicians to countries such as Nigeria or Egypt to ensure some of the
world’s poorest people receive the cancer care they desperately need.
Treating a chronic condition such as cancer is far different from
addressing infections, broken bones or other acute concerns, which can be
handled during relatively short stints in a rural village. Rather, experts told
HemOnc Today that it will require collaboration between medical institutions,
government and nongovernmental organizations, and entities such as ASCO and
ESMO to make progress in the fight against cancer in low-income countries.
Sara Stulac, MD, MPH, director of pediatrics for Partners In
Health, has spent the last few years developing a “twinning” program
in which PIH and Dana-Farber Cancer Institute — under the direction of
Larry Shulman, MD, senior oncology adviser for PIH — provide oncologic
expertise for cancer patients in a country where there are no physicians
trained in cancer care.
The program has since grown to include one hospital in rural Rwanda,
with another expected to launch soon. Each patient is treated by a team
comprised of a Rwandan generalist, a Rwandan nurse coordinator focused on
oncology patients, a Rwanda-based pediatrician or internist trained in the
United States, and a US-based pediatric oncologist.
Biopsies and radiologic staging studies are performed in Rwanda, but all
pathologic diagnoses are made at Brigham and Women’s Hospital. Physicians
from the United States are in-country for 6 months, and, along with local
physicians, are in regular contact with supervisors at Dana-Farber, including
Stulac and Leslie Lehmann, MD, clinical director of the pediatric stem
cell transplant program at Dana-Farber/Children’s Hospital Cancer Center
in Boston. There are weekly conference calls to review all patients, and
outcomes are carefully tracked.
Lehmann — who said there are no trained oncologists in Rwanda, a
nation of roughly 11 million — presented results of a small study at the
2011 American Society of Hematology Annual Meeting and Scientific Exposition
evaluating outcomes among 10 patients aged 3 to 15 years who were diagnosed
with lymphoma. Those patients were treated at Rwinkwavu, a Partners In
Health-supported government district hospital in rural Rwanda.
At a median follow-up of 14 months, five patients had completed therapy,
showed no evidence of recurrence and were considered cured. Two patients were
still undergoing treatment and were in remission. Two patients died due to
treatment complications; one patient with Hodgkin’s lymphoma died of
cardiomyopathy, and one patient with Burkitt’s lymphoma died of transverse
myelopathy. One patient with Burkitt’s lymphoma died of progressive
disease while receiving chemotherapy. One patient with stage I
lymphocyte-predominant Hodgkin’s disease underwent complete surgical
excision and is not receiving chemotherapy.
A 50% cure rate — or 70% if the two patients undergoing treatment
remain in remission — is lower than the 80% cure rate found in the
developed world, and it is nearly impossible to draw definitive conclusions
from such a small cohort. Considering the paucity of resources in a country
such as Rwanda, however, these results represent a tremendous success, Lehmann
“We prioritize what we treat. We’re not treating cancers
unlikely to be curable or cancers with complex and/or costly treatment
regimens,” Lehmann said. “But for a constrained number of cancers,
you can potentially cure a large number of people with a relatively small
investment of resources. Treating cancer is different from treating other
chronic conditions, both in terms of infrastructure required and the knowledge
that, without treatment, virtually all patients would die. In addition, most
patients who are cured can look forward to a return to a healthy life. Because
we backed into this practice, we decided to focus on cancers that are
relatively easy to treat with a higher likelihood of cure.”
Jodi Skiles, MD, a third-year pediatric oncology fellow at Riley
Hospital for Children at Indiana University Health in Indianapolis, has been
traveling to Kenya as part an exchange program with Moi University School of
Medicine in Eldoret, Kenya, for the past 7 years. She recently returned from a
6-month stint there.
Skiles said she caught the “international bug” while working
at Moi as a medical student. An Indiana native, she still remembers the culture
shock she experienced during her first visit to Africa.
“The first 2 weeks I was there as a medical student, I remember
thinking, ‘I’ve made the biggest mistake of my life.’ It took me
about a month to get past feeling overwhelmed so I could recognize the amazing
opportunity before me,” she said. “By the end of the second month, I
didn’t want to go home. It’s so rewarding to know you’re making
a difference on a grander scale. In that setting, there are many clinical
scenarios that you know would have a different outcome had you not been there.
To know that your presence makes such a difference is incredibly rewarding and
inspires me to continue to advocate for change.”
The partnership between the two schools started just before the HIV/AIDS
epidemic in sub-Saharan Africa took hold in the early 1990s. As care for
HIV/AIDS patients in Kenya improved over the years, many patients are now
thriving with HIV. While the HIV patients are now living longer, it has also
resulted in a sharp increase in HIV-related cancers such as lymphoma and
In response, physicians at Moi and Indiana universities began to focus
on adult cancers about 3 years ago, and a pediatric program grew out of that.
Skiles, a specialist in pediatric oncology, served as interim director of the
adult and pediatric cancer programs for 6 months.
Skiles, MD, tends to a pediatric cancer patient during a recent trip to
“One of the things I love most about international work is that a
little bit of education and a little bit of resources can result in drastic
change,” she said. “In this day and age in Western medicine,
there’s not a lot of low-hanging fruit in terms of intervening in a way
that makes a huge impact in clinical care. It’s increasingly more
difficult to make small changes that have a big benefit. In international work,
there is fertile ground for so much growth. It’s so exciting to be part of
something where a relatively small amount of education and resources in the
right hands can accomplish a lot.”
St. Jude Children’s Research Hospital developed its International
Outreach Program in 1993, largely through the efforts of one woman. Her son was
referred to the hospital in Memphis, Tenn., because he needed cancer treatment
that he could not get in their native El Salvador.
“She was very impressed with the model we had here of a very
specific place dedicated to pediatric oncology with full-time nurses, full-time
doctors and a fundraising organization that allowed all kids to be treated
regardless of ability to pay,” said Raul C. Ribeiro, MD, director
of the International Outreach Program at St. Jude. “When she went back,
she tried to emulate this program locally. She built a foundation, she
persuaded the pediatric hospital there to dedicate an area to oncology and to
send a pediatrician to Mexico to be trained in pediatric oncology.”
Then Saint Jude officials approved a one-time request to help develop a
program with El Salvador, and doctors decided to address acute lymphoblastic
leukemia because it is a common, easily curable disease.
“After 3 years, we measured outcomes and noted that we had serviced
155 kids with ALL, and 55 of them were alive,” Ribeiro said. “The
3-year investment was what we would have spent in 1 year treating three
children at St. Jude.”
St. Jude officials were so impressed, they decided to make that model
— an ongoing relationship with a local public hospital dedicated
exclusively to pediatric oncology — a permanent part of its mission. The
program now operates at 19 hospitals in 14 countries. The program’s reach
extends to China, the Middle East, Africa, Central America and South America.
Since St. Jude began working in El Salvador, the cure rate for ALL
improved from 5% to 75%, Ribeiro said. The 5-year survival rate for ALL in the
United States is 89%, according to NCI.
“In many countries, cancer is like a death sentence,” Ribeiro
said. “When we started this program, as many as 40% of families in some
countries abandoned treatment. In talking to other people in the community
whose children had been successfully treated, little by little, that
Results of a survey of the status of pediatric cancer care in 10 low-
and middle-income countries published by The Lancet in 2008 showed
annual government health care expenditure per capita was the strongest
independent predictor of survival (P=.0001), but only for countries with
the lowest annual expenditure.
“About 25% to 30% of patients are not successfully treated, even
with optimum treatment. Therefore, once access to early diagnosis and adequate
care (with the requisite hospital infrastructure) are available, additional
investment of public health resources has a smaller beneficial effect on
survival,” Ribeiro and colleagues wrote. “Because childhood cancer
has a low overall incidence and most patients can be managed without complex
infrastructure or procedures, a relatively small investment by governments or
private sectors in conjunction with local organizations might make a large
difference in survival in low-income and mid-income countries.”
Skiles said all of the chemotherapy offered to her patients is deeply
discounted. Patients pay about $5 per treatment cycle. However, not every
patient can afford to pay even that, so there is constant concern about keeping
the program financially viable.
“Kenya is in the process of developing a health care system that
will be able to support these patients. We are hopeful that the government will
soon help subsidize the costs so that the program won’t be entirely
responsible for the cost of chemotherapy,” Skiles said. “In addition
to clinical care, we’re also doing research. Moving forward, as we open
clinical therapy trials, some of the cost of treatment will be built into the
research funding, which should help relieve some of the financial burden for
care, as well.”
As evidenced by Dana-Farber Cancer Institute’s experience in Rwanda
and St. Jude’s experience in El Salvador, it is not difficult to make
major improvements in survival with relatively minimal investments in these
“Every time we build a structure to treat ALL, we can treat most
pediatric cancers,” Ribeiro said. “The treatment of pediatric cancer
does not depend on new drugs or expensive treatments, like in adult cancer. All
the effective drugs for pediatric oncology were produced in the 1990s. With the
current armamentarium, we can effectively treat 70% to 75% of kids.”
Cancer still may not represent the best use of health care money in
Although adult deaths caused by infectious disease are declining, WHO
said in 2008 that infectious disease represented 64% of deaths in children aged
younger than 5 years and that roughly 75% of all child deaths were caused by
preventable causes such as neonatal conditions, pneumonia, diarrhea, malaria
The 2010 Levels & Trends in Child Mortality report from the UN
Inter-agency Group for Child Mortality Estimation found that the biggest
killers of young children were pneumonia (18%) and diarrheal diseases (15%).
Malnutrition plays a role in one-third of deaths for children aged 5 years and
younger in sub-Saharan Africa and Southern Asia.
Six countries — China, Democratic Republic of the Congo, Ethiopia,
India, Nigeria and Pakistan — represent 50% of deaths in this age group.
WHO’s 2011 World Health Statistics estimated that the number of
underweight children aged younger than 5 years in Africa increased from 24
million in 1990 to 30 million in 2010, and the report estimated that 71 million
children in Asia are underweight. Approximately 178 million children globally
are too short for their age group, a key indicator of chronic malnutrition.
Considering those grim statistics, Lehmann said there may be times when
cancer care must take a back seat. Still, it is a complicated issue with no
“Should you be giving cancer care in a country that doesn’t
have electricity for every inhabitant?” she said. “I don’t know.
It sounds a little ruthless, but I wasn’t asked whether or not cancer care
should be delivered in Rwanda. I came into a system that already existed, and
I’m trying to make it better.” – by Jason Harris
Robert J. Arceci
Every twinning program is going to be unique to the site. There
isn’t one best approach. In the end, a program that ultimately leads to a
country becoming self-sufficient in this area is great. If a developed country
makes a commitment to have people on the ground without the feeling that they
are going to withdraw at any moment, and there is a long-term commitment,
that’s fantastic and enriches both sides.
The world should get smaller and smaller with our ability to travel and
the communications technology we have available. Also, getting on a plane and
traveling to almost anywhere can be done in less than a day.
The only ideal way to conduct one of these programs is the one that
works in a given setting. Everyone will say their way of doing it is the best,
but clearly there are a diverse number of successful strategies. We must do
whatever it takes to get the job done, and there are many, many roads to get
It would be really nice if there was a special international effort in
this area, something that would be completely cross-cultural. I’ve spoken
on this and I don’t think it’s impossible to have a global
comprehensive children’s cancer center. If one could get people to work
together toward that end, it would go a long way toward improving care in other
regions of the world, as well as help to eliminate the still-present gaps in
outcome for children with cancer.
Short-term programs may be extremely effective for surgeons, dentists
and others who can provide a life-changing service during a short visit, but
for cancer care a long-term approach is mandatory. Therefore, any short-term
interventions must be conducted in the context of a long-term program, in which
they help promote, develop, sustain, advertise and advocate the long-term
program. Otherwise, going for 2 weeks or 3 months may be almost the worst thing
one can do (except for the visiting individual, who may experience
Two types of short-term help may be particularly risky. The first is a
short visit to treat oncology patients who have little chance of cure absent
development of a long-term cancer care program. The second is a short-term
grant-funded project in which infrastructure is developed, and people are hired
and trained, but when the term of the grant expires, everything collapses and
leaves behind cynical and demoralized health care professionals.
One example of short-term aid placed in the context of long-term
commitment and support is provided by Texas Children’s Hospital, which
funds a full-time pediatric oncologist in Botswana, and also supports the
on-site clinician with visits by other faculty to assist with teaching or cover
The hospital rotates this person every 1 or 2 years, but with the
understanding that the individual will care for patients and also train local
professionals and eventually develop a self-sustaining oncology program. A
similar program is being implemented in Ethiopia, with the goal to develop an
independent program in a few years. Once the local programs are up and running,
this is only the beginning. The supporting institutions and individuals can
stay involved as twinning partners to facilitate continued improvement in
services and outcomes. The ongoing involvement may involve exchange visits, but
increasingly online case discussion plays a role in day-to-day oncology
collaboration. For example, www.Cure4Kids.org hosts about 100 meetings per
month of oncology professionals worldwide at no cost to participants. Weekly
online contact plus occasional visits to support a long-term twinning program
seems to be the recipe for long-term success, and adding in the energy and new
ideas of short-term visitors makes such programs even more rewarding.
At St. Jude, we used to talk about “knowledge transfer” but
now speak exclusively of “knowledge sharing” — not transfer of
knowledge, but learning from each other. Interaction with colleagues on other
continents paves the way for all of us to become better doctors and human
beings — not short-term aid, but long-term partnership. Only then can we
effectively and sustainably help cancer patients worldwide.
For more information:
- Robert J. Arceci, MD, PhD, is the King Fahd Professor of Pediatric
Oncology at Johns Hopkins University.
- Scott C. Howard, MD, MS, is director of clinical trials for the
International Outreach Program at St. Jude Children’s Research Hospital in
- Drs. Arceci, Howard, Kerr, Lehmann, Ribeiro and Skiles report no
relevant financial disclosures.