Federico Antillon

Protocol-based treatment for children with cancer in low income countries in Latin America: A report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)—Part II

Pediatric cancer programs in low‐income countries (LIC) can improve outcomes. However, treatment must be tailored to the patients living conditions and the availability of supportive care. In some cases, a more intense regimen will decrease survival since the increase in death from toxicity may exceed any decrease in relapse. Attempts to practice evidence‐based pediatric oncology are thwarted by the lack of evidence derived from local experience in LIC to determine optimal therapy. This report summarizes treatment regimens used by pediatric oncologists from 15 countries of the Caribbean, Central and South America who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with hepatoblastoma, Wilms tumor, and histiocytosis treated on unmodified published protocols had outcomes comparable to those in high‐income countries (HIC). Those with rhabdomyosarcoma, osteosarcoma, Hodgkin lymphoma, and acute myeloid leukemia treated with unmodified regimens had event‐free survival estimates 10%–20% lower than those reported in HIC due to higher rates of toxic death, abandonment of therapy, and relapse. Treatment of retinoblastoma is complicated by advanced stages and extraocular disease at diagnosis; improved outcomes depend on education of pediatricians and the public to recognize early signs of this disease. Use of unmodified protocols for Burkitt lymphoma and acute lymphoblastic leukemia have been associated with unacceptable toxicity in LIC, so MISPHO centers have modified published regimens by giving lower doses of methotrexate and reducing use of anthracyclines. Despite the use of all‐trans‐retinoic acid during induction for acute promyelocytic leukemia, the incidence of fatal hemorrhage remains unacceptably high. Pediatr Blood Cancer

Nutritional status at diagnosis is related to clinical outcomes in children and adolescents with cancer: A perspective from Central America

BACKGROUND The prevalence of malnutrition in children may exceed 50% in countries with limited resources. The aims of this study were to assess nutritional status at diagnosis in children and adolescents with cancer, and to correlate it with clinical outcomes in the Spanish speaking countries of Central America that formed the AHOPCA (Asociacion de Hemato-Oncologia Pediatrica de Centro America) consortium. METHODS Patients aged 1-18 years, diagnosed with cancer between 1st October 2004 and 30th September 2007, were eligible for study. Weight (kg) and height or length (m), mid upper arm circumference--MUAC and triceps skin fold thickness--TSFT were measured and their Z-scores or percentiles were calculated. Three categories of nutritional status were defined according to these parameters. RESULTS A total of 2954 new patients were enrolled; 1787 had all anthropometric measurements performed and 1513 also had measurements of serum albumin. By arm anthropometry 322/1787 patients (18%) had moderate nutritional depletion and 813/1787 patients (45%) were severely depleted. Adding serum albumin, the proportion classified as severely depleted rose to 59%. Malnourished children more often abandoned therapy and their event free survival was inferior to that of other children. CONCLUSIONS Arm anthropometry in children with cancer is a sensitive measure of nutritional status. Since malnutrition at diagnosis was related to important clinical outcomes, an opportunity exists to devise simple, cost-effective nutritional interventions in such children that may enhance their prospects for survival.

Toward the Cure of All Children With Cancer Through Collaborative Efforts: Pediatric Oncology As a Global Challenge

Advances in the treatment of childhood cancers have resulted in part from the development of national and international collaborative initiatives that have defined biologic determinants and generated risk-adapted therapies that maximize cure while minimizing acute and long-term effects. Currently, more than 80% of children with cancer who are treated with modern multidisciplinary treatments in developed countries are cured; however, of the approximately 160,000 children and adolescents who are diagnosed with cancer every year worldwide, 80% live in low- and middle-income countries (LMICs), where access to quality care is limited and chances of cure are low. In addition, the disease burden is not fully known because of the lack of population-based cancer registries in low-resource countries. Regional and ethnic variations in the incidence of the different childhood cancers suggest unique interactions between genetic and environmental factors that could provide opportunities for etiologic research. Regional collaborative initiatives have been developed in Central and South America and the Caribbean, Africa, the Middle East, Asia, and Oceania. These initiatives integrate regional capacity building, education of health care providers, implementation of intensity-graduated treatments, and establishment of research programs that are adjusted to local capacity and local needs. Together, the existing consortia and regional networks operating in LMICs have the potential to reach out to almost 60% of all children with cancer worldwide. In summary, childhood cancer burden has been shifted toward LMICs and, for that reason, global initiatives directed at pediatric cancer care and control are needed. Regional networks aiming to build capacity while incorporating research on epidemiology, health services, and outcomes should be supported.

Treatment‐related mortality in children with acute lymphoblastic leukemia in Central America

The objectives of this study were to describe the incidence, timing, and predictors of treatment‐related mortality (TRM) among children with acute lymphoblastic leukemia (ALL) in El Salvador, Guatemala, and Honduras.

AMOR: A proposed cooperative effort to improve outcomes of childhood cancer in Central America

The dramatic reduction of pediatric cancer mortality rates has been one of the greatest accomplishments of contemporary medicine. About 80% of children with cancer are now expected to be cured by current therapies. However, most of the worlds children have no access to cancer treatment. The translation of effective pediatric cancer therapies to impoverished regions of the world presents an enormous challenge to the health care profession. Over the past 20 years, efforts have been under way to extend adequate cancer treatment to an increasing number of children in developing countries. These initiatives, collectively designated “twinning programs,” consist essentially of a partnership between a pediatric cancer unit in a developing country and a group of health care providers in the developed world. Here we review the twinning programs that have been implemented in Central America, discuss their impact on the development of local resources and the outcome of childhood cancer, and propose a collaborative research initiative aimed at improving the international dissemination of progress in pediatric hematology‐oncology.

Nutritional status of children during treatment for acute lymphoblastic leukemia in Guatemala

Most children with cancer live in developing countries where the prevalence of malnutrition may reach 50% and influence the course of the disease. This study examined the prevalence and severity of malnutrition at diagnosis, as well as after 3 and 6 months of chemotherapy, in children with acute lymphoblastic leukemia (ALL) in Guatemala.

Nutritional status in children with cancer: a report from the AHOPCA Workshop held in Guatemala City, August 31-September 5, 2004.

More than 85% of children with cancer live in developing countries [1] where malnutrition is a major publichealth issue and it is widely accepted that the prevalence of under-nutrition in this setting varies from 8% to 43% [2]. Under-nutrition can influence the course of cancer treatment and survival. Some authors have described a decreased tolerance of chemotherapy [3], associated with altered metabolism of antineoplastic drugs, increased infection rates [4], and poor clinical outcome. However, the relationship between malnutrition and morbidity/ mortality is still controversial in both developed and developing countries. Some authors have found a correlation [5–7], while others have not [8–11]. Unfortunately, with current knowledge, it is not possible to reach a definitive conclusion, since all the previous studies were based on a small sample size, were focused mainly on acute lymphoblastic leukemia (ALL), and did not use a uniform method of assessing nutritional status [12]. To date there is still little information on formal comparisons of different measures (clinical examination, dietary intake, anthropometry, biochemistry, etc.) [13] that could define the best way to determine nutritional status. There is some evidence that confidence in simple measures (e.g., weight and height) is misplaced when better methods of assessment are used (e.g., armanthropometry). For example, children with abdominal tumors may have masses that weigh more than 10% of their total body weight [14]. In such patients, the use of arm anthropometry in assessing nutritional status is valuable because it is independent of tumor mass [15–17].

A sustainable model for pediatric oncology nursing education in low-income countries

Effectiveness of a nurse educator in the pediatric oncology unit in Guatemala was assessed by measuring completion of an education course, chemotherapy and central line competency, continuing education, and cost. All newly hired nurses completed the education course. Of the nurses employed, 86% participated in the chemotherapy course, and 93% achieved competency; 57% participated in the central line course, and 79% achieved competency. The nurses completed a mean of 26 hours continuing education yearly. The annual direct cost of the educator (

Use of traditional and complementary/alternative medicine (TCAM) in children with cancer in Guatemala

244/nurse) was markedly less than other models. This is an effective and sustainable means to educate nurses in low‐income countries. Pediatr Blood Cancer 2012; 58: 163–166.

Global Pediatric Oncology: Lessons From Partnerships Between High-Income Countries and Low- to Mid-Income Countries

International surveys have demonstrated that use of traditional and complementary/alternative medicine (TCAM) is highly prevalent among children with cancer; however, little is known about its use among children with cancer in Latin America. As part of a regional initiative, we present the results of the first survey exploring use of TCAM among children with cancer residing in Latin America.