E-ISSN 1858-8360 | ISSN 0256-4408
 

Letter to the Editor 


SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 1

LETTER TO THE EDITOR

Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement

Moawia Mohammed Ali Elhassan (1)

(1) Department of Oncology, National Cancer Institute, University of Gezira, Wad Medani, Sudan

Correspondence to:

Moawia Mohammed Ali Elhassan

Clinical and Radiation Oncologist, Associate Professor of Oncology, The National Cancer Institute, University of Gezira, Wad Medani, Sudan

Email: moawia2 [at] gmail.com

Received: 28 August 2020 | Accepted: 19 October 2020

How to cite this article:

Elhassan MMA. Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudan J Paediatr. 2021;21(1): 102–104.

https://doi.org/10.24911/SJP.106-1598567827


Dear Editor,

Elhaj et al [1] in a well-written article explicitly described the clinical presentation and outcome of neuroblastoma in children treated at the National Cancer Institute – University of Gezira (NCI-UG), Sudan. It is clearly evident that most of Sudanese children with neuroblastoma tend to present with advanced stage at diagnosis and have a poor outcome to treatment. The authors attributed the high mortality to late presentation of the patients, lack of healthcare awareness and limited access to diagnostic and treatment facilities. Therefore, achieving earlier diagnosis of symptomatic children with neuroblastoma is an important step in reducing the morbidity and mortality from this disease. Indeed, this can be done through increasing awareness of health care professionals on the early signs of neuroblastoma and improving access to diagnostic facilities. Moreover, research studies related to reducing barriers to care and down-staging of neuroblastoma are urgently needed in Sudan.

It is clear from the facilities mentioned by the authors that the neuroblastoma treatment in Sudan is not fulfilling the standard of care in the Western centers [1]. Stefan et al. [2] explained how inadequate resources for treatment and care in low- and middle-income countries (LMIC) leads to underdiagnosis of childhood tumours. In Sudan, there are limited number of well-trained staff with in-depth knowledge of the management of children with cancer, deficiencies of the necessary medical equipment for diagnosis and treatment together with a paucity of resources and financial constraints. Moreover, the health system is facing a high burden of other pressing health issues to contend with including malaria, diarrhoeal diseases, tuberculosis, malnutrition and mother and child health. This situation reflects the difficulties faced in the building of complex and expensive cancer care programs. Therefore, improvements in diagnostic and treatment facilities should contribute when possible to general pediatric care. Furthermore, ‘a single well-equipped pediatric oncology center offering a multidisciplinary service performed by well-trained staff and according to recognised treatment protocols may be necessary to save effort and money and ensure a better outcome’ [3]. Additionally, there is a significant need to develop local specialised training programs tailored to the local needs. These programs could be better achieved through active collaborations with international organisations such as: International Society for Pediatric Oncology (https://siop-online.org/), International Society of Pediatric Surgical Oncology (https://ipso-online.org/), Union for International Cancer Control (https://www.uicc.org/) and International Atomic Energy Agency (https://www.iaea.org/).

The MYCN gene status is critical to differentiate between intermediate and high-risk disease for all stage 3 and stage 4 patients <18 months of age. Children > 18 months with stage 4 would be treated based on high-risk protocol [4]. Yet in Sudan, access to MYCN gene testing is lacking [1]. The deficiency of such an essential biological test may lead to overtreatment due to inaccurate risk stratification. Therefore, treatment of neuroblastoma in limited resource settings should take into consideration this diagnostic limitation. High levels of lactate dehydrogenase > 750 IU/L and ferritin levels > 120 ng/ml suggest correlation with MYCN amplification, and therefore, may serve as useful surrogate for MYCN amplification [5]. In limited resource settings, these markers could help in guiding treatment decision, until MYCN gene testing is readily available.

Elhaj et al. [1] reported that 33 patients died which represented 87% of their study population; and sepsis secondary to cancer treatment was the cause of death in 23 (70%) cases. This high infection-related mortality is apparently due to limited supportive measures such as availability of antibiotics, granulocyte colony stimulating factor (G-CSF), intensive care unit, infection control and patient living conditions. Additionally, intensive chemotherapy regimens recommended for high-risk neuroblastoma are associated with prolonged bone marrow suppression and increased mortality secondary to neutropenic sepsis. As a result, these regimens cannot be adopted by most pediatric oncology units in Africa [6]. Therefore, use of metronomic therapeutic approach, frequent administration of chemotherapy at doses below the maximum tolerated doses with no prolonged drug-free break, in low-income countries would be a reasonable option for children with high-risk neuroblastoma [6,7].

In the face of these challenges, among many others, associated with management of neuroblastoma in countries with limited resources like Sudan, a strong effort has been led by the Pediatric Oncology in Developing Countries (PODC) Committee of the International Pediatric Oncology Society (SIOP) to improve outcomes of childhood cancer in LMIC. In this regards, SIOP-PODC has developed treatment practice guidelines that provide adapted treatment strategies for neuroblastoma in LMIC where diagnostic and treatment strategies lag behind those in high-income countries [5,8]. Furthermore, these guidelines provide an opportunity to cure as many children as possible with the available resources, while working to improve services and supportive care.


REFERENCES

  1. Elhaj NOY, Nugud FA, Abuagla OA, Mohamedani AA, Haroun HM. Neuroblastoma in Sudan: experience of a single institute. Sudan J Paediatr. 2020;20(2):122-5. https://doi.org/10.24911/SJP.106-1570515379
  2. Stefan C, Bray F, Ferlay J, Liu B, Maxwell Parkin D. Cancer of childhood in sub-Saharan Africa. Ecancermedicalscience. 2017;11:755. https://doi.org/10.3332/ecancer.2017.755
  3. Zaghloul MS. A single well-equipped pediatric oncology center may improve the results in low-/middle-income countries. Childs Nerv Syst. 2019;35(4):591-2. https://doi.org/10.1007/s00381-019-04094-3
  4. Cohn SL, Pearson AD, London WB, Monclair T, Ambros PF, Brodeur GM, et al. The International Neuroblastoma Risk Group (INRG) classification system: an INRG Task Force report. J Clin Oncol. 2009;27(2):289-97. https://doi.org/10.1200/JCO.2008.16.6785
  5. Parikh NS, Howard SC, Chantada G, Israels T, Khattab M, Alcasabas P, et al. SIOP-PODC adapted risk stratification and treatment guidelines: Recommendations for neuroblastoma in low- and middle-income settings. Pediatr Blood Cancer. 2015;62(8):1305-16. https://doi.org/10.1002/pbc.25501
  6. Traore F, Eshun F, Togo B, Yao JJA, Lukamba MR. Neuroblastoma in Africa: A Survey by the Franco-African Pediatric Oncology Group. J Glob Oncol. 2016;2(4):169-73. https://doi.org/10.1200/JGO.2015.001214
  7. Fousseyni T, Diawara M, Pasquier E, Andre N. Children treated with metronomic chemotherapy in a low-income country: METRO-MALI-01. J Pediatr Hematol Oncol. 2011;33(1):31-4. https://doi.org/10.1097/MPH.0b013e3182018ab8
  8. Parkes J, Hess C, Burger H, Anacak Y, Ahern V, Howard SC, et al. Recommendations for the treatment of children with radiotherapy in low- and middle-income countries (LMIC): A position paper from the Pediatric Radiation Oncology Society (PROS-LMIC) and Pediatric Oncology in Developing Countries (PODC) working groups of the International Society of Pediatric Oncology (SIOP). Pediatr Blood Cancer. 2017;64 Suppl 5. https://doi.org/10.1002/pbc.26903


How to Cite this Article
Pubmed Style

Moawia Mohammed Ali Elhassan. Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudan J Paed. 2021; 21(1): 102-104. doi:10.24911/SJP.106-1598567827


Web Style

Moawia Mohammed Ali Elhassan. Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. http://www.sudanjp.com/?mno=129357 [Access: October 16, 2021]. doi:10.24911/SJP.106-1598567827


AMA (American Medical Association) Style

Moawia Mohammed Ali Elhassan. Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudan J Paed. 2021; 21(1): 102-104. doi:10.24911/SJP.106-1598567827



Vancouver/ICMJE Style

Moawia Mohammed Ali Elhassan. Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudan J Paed. (2021), [cited October 16, 2021]; 21(1): 102-104. doi:10.24911/SJP.106-1598567827



Harvard Style

Moawia Mohammed Ali Elhassan (2021) Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudan J Paed, 21 (1), 102-104. doi:10.24911/SJP.106-1598567827



Turabian Style

Moawia Mohammed Ali Elhassan. 2021. Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudanese Journal of Paediatrics, 21 (1), 102-104. doi:10.24911/SJP.106-1598567827



Chicago Style

Moawia Mohammed Ali Elhassan. "Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement." Sudanese Journal of Paediatrics 21 (2021), 102-104. doi:10.24911/SJP.106-1598567827



MLA (The Modern Language Association) Style

Moawia Mohammed Ali Elhassan. "Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement." Sudanese Journal of Paediatrics 21.1 (2021), 102-104. Print. doi:10.24911/SJP.106-1598567827



APA (American Psychological Association) Style

Moawia Mohammed Ali Elhassan (2021) Treatment of pediatric neuroblastoma in Sudan: challenges and opportunities for improvement. Sudanese Journal of Paediatrics, 21 (1), 102-104. doi:10.24911/SJP.106-1598567827





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