Childhood Cancer in Africa – Part 3
These days, most childhood cancers can be cured, but as each patient is different, how well treatment works will depend on the type of cancer, the child’s age, and various other factors. Cancer treatment can cause unwanted side effects for young patients, as well as other problems during and after treatment.
While early treatment of cancer symptoms and the side effects of therapy help patients feel better, stay stronger, and cope with life after cancer, it is Supportive Care that improves the patient’s physical, psychological, social, and spiritual quality of life.
Improvements in supportive care have been shown to impact positively on outcomes for Children with Cancer in Africa too, but despite ongoing efforts, to date no single comprehensive qualitative report exists that examines the status of supportive care facilities in African POUs.
Supportive Care in Africa
In the survey regarding supportive care, 10 responses were received from eight countries: Cameroon, Ghana (2), Malawi, Morocco, Nigeria (2), Tanzania, South Africa, and Uganda. Only in one POU were supportive-care drugs fully funded by the state.
While pretty much all of the units have access to certain medication such as penicillin, aminoglycosides, cephalosporins, and fluconazole, they do not all have many others. Only four units provided TB therapy and prophylaxis, whereas all others were limited by combination anti-TB medicines, preventing INH prophylaxis. Access to HAART was good in eight units, although the time from diagnosis to the commencement of HAART varied by several weeks between services, mostly due to access.
While all units had access to nasogastric tube feeding, but in some units, continuous infusion was impossible due to the expense of feeding pumps, and, in one unit, parents found it undesirable. Only one unit had ready access to total parenteral nutrition, and another reported access only if the parents paid for it themselves. Artificially formulated semi-elemental feeds were only available in South Africa, having only just become available in Uganda’s private sector.
Access to PICU services was non-existent or limited. Five units reported poor or no access to intravenous morphine, two had no access to oral morphine suspension, and although four units had access to slow release morphine tablets, in two it had to be purchased privately.
Only one POU reported state-supported patient transport, while other units relied on donations for this purpose. Four units could provide accommodation for parents, and in two units parents either could sit at the bedside, or sleep on the floor.
Paediatric Palliative Care in Africa
Late diagnosis of cancer is common in Africa, which means that palliative care with pain relief is often the only option, but effective pain relief is often problematic due to weak health systems and regulations that limit the availability of opioids.
Paediatric palliative care (PPC) can be provided in hospitals, primary health-care facilities, and at the child’s home. On classifying countries providing PPC, according to the four Observatory on End of Life Care (OELC) levels, Knapp et al. found that the majority of African countries were level 1 (81%), 13.2% were level 2 (Egypt, Kenya, Nigeria, Malawi and Tanzania), 3.8% were level 3 (Uganda and Zimbabwe), and only one country (South Africa) was level 4
Challenges included lack of funds for basic health care and trained health-care workers, inadequate doctor-patient ratios, lack of general public or policymaker awareness, and the unavailability of morphine. In addition, cultural beliefs were found to play an important role in Africa, sometimes preventing families from seeking help for a dying child.
A successful strategy for improving PPC was to change the legislation that allows trained nurse practitioners to prescribe morphine in rural areas, following the example of Uganda.
Another initiative for developing PPC in Africa is the establishment of pilot Beacon Centres in South Africa (HPCA), Uganda (Mildmay) and Tanzania (PASADA), which provide training opportunities for health professionals.
Advocacy in Africa
The sustainability of health-care programmes in Africa remains a challenge, especially when potential funders pose this question to NGOs fund-raising for health-care packages for specific diseases in LMICs. These programmes, however, do offer small groups of children the potential for cure. Until these countries have pro-poor financing and universal health-care systems, such programmes offer training and provide models for good clinical practice, while advocating for child health.
SIOP has held biannual continental meetings in Africa since 1994, creating a network of health-care professionals involved in paediatric oncology, and has led to successful twinning programmes in Malawi and Cameroon. Together with the International Confederation of Childhood Cancer Parent Organisations (ICCCPO) and other local parent organisations, doctors and nurses have advocated for better access to care among policymakers in individual African countries.
Addressing the challenges in Africa will require a collaborative effort by the health-care workers and parents who are involved in the care of children with cancer and SIOP, offering networking opportunities through African meetings. A stepwise approach involves integrating childhood cancer treatment with existing general paediatric health care, and the prioritisation of feasible interventions within the framework of available health-care resources. Local tumour registries to document childhood cancer prevalence will assist policymakers in budget allocation, and should be a priority in Africa.
A resource-focused approach would harness existing clinical services to expand childhood cancer care. A disease-focused approach targets specific diseases for study or intervention, and is exemplified by SIOP’s PODC recommendations for managing BL and KS in low-income settings.
Source: Childhood Cancer in Africa