A symphony or a raga...or both Gupta S - Indian J Med Paediatr Oncol

A symphony or a raga...or both Gupta S - Indian J Med Paediatr Oncol

I read this editorial in the Indian Journal of Medical and Pediatric Oncology today. I loved the way he wrote about the different philosophies of Indian and Western classical music and compared it to the oncology scene in those settings. Formation of co-operative groups have been critical to the progress against cancer in the West. The lack of similar co-operative groups in India is a gap which needs to be urgently filled. The formation of the Indian Pediatric Oncology Group nearly 3 years ago was a welcome development. I look forward to their work.

My Highlights of SIOP 2011

Going to the Annual Congress of SIOP is always a worthwhile experience for me as it allows learning and networking. Also special is the opportunity to engage with the paediatric oncology community from India who I have started to get to know over the years. A welcome recent trend I have noticed is the increased participation of paediatric haem/onc fellows from India as well as paediatric residents with an interest in paed haem/onc. This is likely to be as a result of the several fellowship programmes which are now up and running in India. Again this is a welcome development.

Among others I met Vikas and Mohammed from Sir Ganga Ram Hospital, Narendra from Manipal Hospital, Pinky from BJ Wadia Hospital, Kajal from Tata Memorial Hospital, Sneha from Chattrapati Shahuji Maharaj Medical University (previously known as KGMC) in Lucknow and Vaishnavi from Sri Ramachandra Institute. They made some excellent oral and poster presentations and I look forward to seeing their work in print.

The presentations from India which stood out for me were

Tushar Vora's excellent oral presentation on the Impact of holistic housing care at St Jude India Childcare Centres on morbidity and mortality during treatment of Acute Lymphoblastic Leukaemia. Only 1 out of the 60 children (1.6%) who were provided housing at that centre abandoned treatment compared to 21 out of the other 324 children (6.4%) who were treated at Tata Memorial Hospital at the same time but were not provided housing at St Jude.

Data from AIIMS on the NB96 neuroblastoma protocol over a 14 year period which showed a 3 year overall survival of 60.7% (Stage 1 and 2 - 100%, stage 3 - 71.5% and stage 4 - 35.7%). 56.9% of stage 3 patient and 17.6% of stage 4 patients were in clinical remission.

Mohammed Ramzan's poster from Sir Ganga Ram Hospital (Treatment abandonment is a major hurdle for improving survival in childhood cancer in the developing world) showed data on 146 parent of children with cancer who had abandoned treatment and 57 (40%) of these children had died. When they were interviewed on the phone, 28 of them had opted for no further treatment for their children (of which 24 died), 27 had opted for alternative treqatment (and 12 had died), and 78 had opted for chemotherapy at another centre (of whom 21 had died).

On a final note, I was still looking for that elusive multi-centre study from India which has yet to materialise. Perhaps London 2012 ........

Abandonment of treatment for childhood cancer: A Position Statement by the SIOP PODC Working Group

When I look at the outcomes of children with cancer in developing countries including India and try to understand the survival gap with that seen in the developed world, the one fact which strikes me most is the high level of children with cancer who abandon treatment. This is as much a social issue as it is a medical one. There is a need to recognise this, measure it, report it and then tackle it. In this regard, I would like to bring to your attention, the recently published position statement of the SIOP PODC Abandonment of Treatment of Working Group (Mostert et al, 2011).

"Almost 80% of children with cancer in resource-rich countries can be cured by timely, intensive multimodality treatment and robust supportive care. However, only 20% of the world's children with cancer live in these countries; the remaining 80% reside in resource-poor nations and have a substantially lower chance of survival. Abandonment of treatment is a major cause of therapeutic failure in these resource-poor countries, affecting up to 50—60% of cases.4 Abandonment constitutes failure to start or complete curative treatment (except in situations when such treatment is contraindicated for medical reasons—eg, the patient is too ill).

At the 2010 Congress of the International Society of Pediatric Oncology (SIOP), the Abandonment of Treatment Working Group was established as one of 12 new working groups within the Pediatric Oncology in Developing Countries (PODC) structure. Its aims are to: heighten awareness of abandonment as a major cause of treatment failure in resource-poor countries; to elucidate the contributing factors; and to identify and widely disseminate effective solutions. To enable comparisons of studies worldwide, the international paediatric oncology community must adopt consistent terminology and reliably identify and document abandonment. Only in this way can the magnitude of the global problem be measured accurately, the underlying causes ascertained, and solutions devised.

For these reasons, the Working Group offers five recommendations. First, we recommend that abandonment of treatment be documented as an adverse event in childhood cancer studies in resource-poor countries. Patients who do not begin or complete treatment should not be excluded from survival analyses. Event-free survival should be analysed in two ways: by treating abandonment as an adverse event and by censoring cases at the time of abandonment. Because some children might be cured if they abandon treatment after completing most of their planned therapy, these two estimates will reflect the upper and lower bounds of the true event-free survival estimate. Second, we propose that abandonment of treatment be defined as failure either to begin (conventionally termed refusal) or to continue the planned course (abandonment), because both are likely to have related underlying causes and could benefit from similar interventions. However, the timing of abandonment should be documented to help to identify related factors. Third, treatment in resource-poor settings might be interrupted for various reasons, including financial and transportation difficulties. When such interruptions herald full abandonment and what the effect on outcomes will be are difficult to predict. We suggest that abandonment of treatment be defined as a hiatus of 4 or more weeks in the scheduled treatment; this period is based on empirical evidence and on anecdotal observations that, after an absence of this length, patients are unlikely to return. In the rare event that patients do return after a prolonged interruption, the treatment options might be limited in the setting of refractory disease or imminent death. Further research will help to establish whether this 4-week working definition needs revision. Fourth, we recommend that abandonment of treatment should be used only in the context of treatment given with the intention of cure. However, if palliation is the only achievable goal because of disease factors or poor socioeconomic conditions (particularly relevant in resource-poor countries), these children must be documented carefully, tracked, and analysed to elucidate the reasons underlying the administration of solely palliative, symptomatic, or end-of-life care to children with curable cancers. Finally, the Working Group recognises that some might perceive the term abandonment of treatment as implying that the patients and their parents are solely responsible; we emphasise that this is not the case. Abandonment of treatment is as much a socioeconomic issue as a medical one, and is often the result of various factors beyond the control of the patients and parents.

Abandonment of treatment can no longer be ignored by the international paediatric oncology community. The members of our Working Group offer these recommendations in the belief that all children with cancer have the right to an equitable chance of survival."

Multi-Centre Study on Pediatric Brain Tumours in India

In India, CNS tumours are the third most common childhood cancer behind leukemias and lymphomas. However, CNS tumours are a heterogeneous collection of many pathologies and till recently there has been limited data from India describing their epidemiology. For this reason the recent paper in Neurology India made welcome reading (Jain et al, 2011). In terms of results, the paper does not offer anything spectacularly new. The most common primary pediatric brain tumors were astrocytic tumors (34.7%), followed by medulloblastoma and supratentorial primitive neuro-ectodermal tumors (22.4%), craniopharyngiomas (10.2%) and ependymal tumors (9.8%). The most common astrocytic tumor was pilocytic astrocytoma.

The two main caveats to interpreting this information are - that it is not population-based data and the information is collated from pathology reports. Upto 20% of childhood CNS tumours may be diagnosed on the basis of radiology only and this group of tumours would be missing.

Despite all this, what has been most fascinating for me is the fact that this paper is a joint effort of seven institutions with nearly 4000 childhood CNS tumour patients. Such multi-institutional studies are not frequent in the paediatric haematology-oncology literature from India and the effort of the authors needs to be acknowledged.

Wilms Tumour in India

Carl Max Wilhelm Wilms was a German pathologist and surgeon who worked extensively on renal tumours towards the end of the 19th century. One of the most common solid tumours in children, nephroblastoma, is also known as Wilms tumour in recognition of his work. In resource-rich countries, the five-year survival for this cancer is 90% and the focus now is on reducing the treatment-related morbidity while maintaining similar outcomes.

Despite being a relatively common childhood cancer, there have been no published studies from India on the outcome of this cancer for over a decade. It is for this reason, that the recently published report from PGI Chandigarh (Trehan et al, JPHO, 2011) is so timely. 23 children with Wilms tumour were seen over a five year time period (1999 to 2003). Three did not start treatment and abandoned after diagnosis. In the remaining 20 treatment was based on the SIOP philosophy of neoadjuvant or preoperative chemotherapy. There was one treatment related mortality (5%), three relapses (15%) and one abandonment on therapy (5%) leading to a five-year event-free survival of 75%.

Detailed analysis of causes of treatment failure would be needed to further improve outcomes. What is noteworthy is that the three relapses happened in two Stage II patients and one Stage III patients. Staging of the chest was done by x-ray which would be standard practice in many centres in India. I wonder whether a CT Chest may have upstaged these patients at diagnosis and consequently they might have received more intensive chemotherapy leading to reduced risk of relapse. I think it is a question worth answering in the future.

How does this compare to other centres in India? The difficulty is the lack of published and peer-reviewed literature. Nevertheless, long term event-free survival of 73% and 77% have been reported from Tata Memorial Hospital (SIOP 2005) and AIIMS (SIOP 2009) based on data obtained from scientific presentations of annual SIOP congresses.

Good old, Ginger

The recent Pediatric Blood cancer made for happy reading when I saw the very interesting piece of work from AIIMS on the use of GINGER in the control of nausea and vomiting in children with cancer (Pillai et al, PBC, 2011). It is encouraging to see that this root, which is so essential to Indian cooking, has been harnessed for therapeutic use. Dr Bakshi and his team should be congratulated on a simple well-designed trial with a clear message. I look forward to use of ginger and its effect in other settings, other centres, and other chemothrapy regimens.