The new Rolls-Royce is a stunning example of modern technology: it not only features climate control for all four seats, but also massage chairs, umbrella’s hidden in the doors and a humidifier. The engine is state of the art and build with the finest materials and its safety is according to the manufacturer unsurpassed. It even has a malfunction detector that will automatically inform you as well as the garage that a certain part of the car is – or about to become – broken and should be replaced. So the question is: would we use this car to drive from Kinshasa to Harare? Probably not, unless you own a couple of them. The roads are not made for its suspension, the precious white leader seats too vulnerable for Africa’s black mud and if the car breaks down, spare parts cannot be found anywhere on the continent. Driving a Rolls-Royce through Africa is generally considered a laughable act of stupidity.
Pediatricians at the Academic Medical Center (AMC) in Amsterdam have initiated a pediatric oncology program in Malawi in collaboration with doctors from Stellenbosch University in South-Africa, who were already involved in treating childhood malignancies in Sub-Saharan Africa. Their main focus has been on Burkitt’s lymphoma, Wilms’ tumor and Karposi’s sarcoma. The first two are potentially curable diseases, while the latter is usually not. During a symposium at the AMC on 29 April, their latest result were shown to the public. It was all organized as a special celebration for Ms Trijn Israels’ PhD-thesis, which she successfully defended the day before. A subject of her research has been treating Wilms’ tumor in children in Malawi.
Treating Wilms’ tumor in the West is challenging: it requires a solid combination of chemotherapy, radiation and surgery to obtain favorable results and remission. After the first rounds of chemotherapy to downstage the tumor, patients should be optimally prepared for surgery. Duration of post-nefrectomy chemotherapy and radiation depends on the stage and grade of the tumor that can only be assessed after histopathological examination. During the whole course of treatment, healthcare staff should be fully concentrated on signs of toxicity, developing of fever or nausea and need for blood or platelets transfusion. To have a child with Wilms’ tumor on the ward is highly demanding for the medical as well as the non-medical staff.
In a pilot study in Malawi between 2006 and 2008, a total of 20 patients with Wilms’ tumor were included. Compared to European standards, children often presented at a late stage of the disease and 8 patients (40%) already had metastases. Of the 12 other patients who were able to undergo surgery after initial chemotherapy, 8 were still alive after the full treatment with a median follow up period of 8 months (survival rate 40%).
The picture with the treatment of Burkitt’s lymphoma (BL) is somewhat more encouraging. BL has a high prevalence in Sub-Saharan Africa that co-incites with the holo-endemic area for malaria. Increased exposure to the ubiquitous Epstein-Barr virus in combination with malnutrition is furthermore assumed to explain the existence of a ‘lymphoma belt’ that runs from Ivory Coast to Tanzania like a girdle around Africa’s waist.
BL is an aggressive tumor and Denis Burkitt already found out in Uganda in 1958 that a single dose of cyclophosphamide can make the tumor disappear like snow through sunshine. After Denis Burkitt first discovery, the world of pediatric oncology has moved forward like a high-speed train and European protocols exist for every stage of this disease. Overall cure rates are somewhere between 90% – 80% and most hazards derive from the treatment itself, like tumor lysis syndrome and septicaemia in a neutropenic patient. So when physicians of the Stellenbosch University and the AMC started to treat BL in Malawi using European protocols, it became a fair disappointment with many children dying from the toxic effects of the chemotherapy (survival rate just over 50%).
And so adjustments were made and instead of combining four cytotoxic agents to combat the malignant cells, cyclophosfamide monotherapy was developed as the standard treatment with the addition of intra-thecal methotrexate in stage 1 and 2 tumors. Additionally, the duration of treatment was decreased from 52 to 28 days. The yielded results were impressive: in stage 1 and 2 tumors, survival rates of 90% and 70% respectively were achieved. Patients with a stage 3 tumor have a 60% 1 year survival rate. The results in stage 4 tumors with CNS involvement continue to be dismal: only 10% of patients is still alive after 1 year. It needs to be emphasized that children with BL only have a 5% risk of relapse after the first year of remission.
Can the care for children with cancer be feasible in Africa? Patients often present at a very advanced stage of the disease, most come from rural areas which brings plenty of obstacles for the follow-up, many are malnourished and anemic even before initiation of treatment which further increases the risk of surgery and/or opportunistic infections, hospitals require a blood bank and well trained staff to observe and manage side-effects, supportive and palliative care including morphine should always be available and Western trained pediatricians with experience in oncology should be within arm’s reach to educate local staff.
It is highly respectable that pediatricians have taken up this challenge, are willing to face and deal with the hurdles that lay ahead and refuse to neglect the fate of children who suffer from a deathly disease that does not carry the name malaria, malnourishment, tuberculosis, diarrhea or HIV/AIDS. That they have chosen to do so by adjusting their own familiar Rolls-Royce treatment to the situation on the ground in Africa is a first step, but many more will have to be taken to make this initiative a success, particularly in regard to pushing back the number of patients that present at a advanced stage of disease.
