5 Types of Paediatric Cancer You Need to Know About

Here is another one I wrote a few years ago on the Max Healthcare platform. This talks about the 5 Types of Paediatric Cancer You Need to Know About

https://www.maxhealthcare.in/blogs/5-types-paediatric-cancer-you-need-know-about

Dinutuximab (Anti GD2 therapy) for children with high risk neuroblastoma now available in India

 High risk neuroblastoma continues to be a childhood cancer which is challenging to treat and has poor outcomes. While smaller increments in survival have been made over the years, a big step-up in survival was when Anti-GD2 therapy (now known as Dinutuximab) was introduced and this was published by Yu et al in this landmark study. I had written a blog on this in 2010 and also reflected on the Indian situation. Since then Dinutuximab has become the standard of care for high risk neuroblastoma in high-income countries.

Low and middle income countries like India have not had access to the medicine, either through clinical trials, or through compassionate use. This has now changed and the first child received Dinutuximab in Mumbai last year and this was covered in the media - Mumbai child receives special injection to treat rare cancer. Subsequent to this, I have been informed that another child has received this treatment in Bangalore and there are a few others waiting to receive it.

While this is exciting and welcome, it is important to point out that AVAILABILITY does not equate to ACCESSIBILITY. And the main reason for that in this context is AFFORDABILITY. This drug is not manufactured in India but imported from Europe. Based on the information available to me, a child who weighs around 13 kg will need 3 vials per cycle and a total of 15 vials for 5 cycles. With each vial 11,000 Euros, the total cost is approximately INR 1.4 cr + 25% custom duties. With the right kind of paper-work and eligibility for discount, the custom fees may be waived off and the price of the drug could come down to INR 56 lakh. But this still remains out of reach of almost all children with high risk neuroblastoma in India.

In conclusion, it is a welcome positive step that Dinutuximab in now available in India. With time and increased use, we hope and expect the price to be driven down so that it becomes accessible to more children who need it.

 

In India, should we treat children with High Risk Neuroblastoma (HR NB)?

At the outset, let me clarify two things. Firstly, by no means am I advocating not giving treatment to children with HR NB in India. My only purpose is to generate debate and learn from the more experienced and learned clinicians in India who manage children with this cancer. Secondly, every child irrespective of the type of disease or cancer (including HR NB) has a right to palliation including pain relief and this treatment option should not be denied. So, I guess the question I am really asking is "In India, should we treat children with HR NB with a curative intent?"

Around 50% of all children with NB have HR disease (essentially Stage IV i.e. metastatic NB or NB with mycn gene amplification with some caveats for age and histology). A study from the Children's Oncology Group published last month (Yu et al, 2010) reports a 2-year overall survival of 86% and event-free survival of 66% in children with HR NB who were treated with multi-drug induction + stem cell transplantation + isotretinoin + immunotherapy. Prior to the introduction of immunotherapy, the event-free survival in the developed world had plateaued at less than 50%. Thus, this new report of further improvement in outcomes is significant.

This brings me to the situation in India. As far as I am aware, while multi-drug induction (followed by surgery and radiotherapy) is standard treatment for children with HR NB, use of stem cell transplantation is not standard and immunotherapy has not been tried. In such a setting, what are the outcomes of HR NB? It is difficult to answer this question precisely, because assessment of mycn amplification is not standard practice in India either. Outcome of children with Stage IV i.e. metastatic NB can give us some indication, although very few institutes from India have published their outcomes. This includes 3 long term survivors out of 32 children with Stage IV neuroblastomas reported from Thiruvanathapuram (Kusumakumary et al, 1998); 1 out of 27 reported from Chandigarh (Bansal et al, 2008); and 0 out of 38 reported from Mumbai (Bhatnagar et al, 2007, SIOP).

Based on these reported outcomes i.e. less than 10% reported long-term survivors of HR NB, is there an argument for not offering curative treatment to the above group of patients in India? Has anybody reported better outcomes from India?