by Hedieh Mehrtash
The current, and soon to be expired Millennium Development Goal 4 (MDG 4), is to reduce childhood mortality in under-fives by two thirds. In the past decade, global efforts to reach this goal have focused on scaling up access to childhood vaccines, oral rehydration salts, malaria treatment and prevention, and prevention of mother to child transmission of HIV in Southern Asia and sub-Saharan Africa.
Since the inception of the MDGs there has been increasing recognition of the burden of non-communicable diseases (NCDs) globally, not just as diseases of high-income countries. The post-2015 development agenda seeks to accommodate this shift as articulated in roadmaps such as the WHO Global Action Plan for NCDs.
This blog post looks at where child health and NCDs intersect in the MENA region, with a specific focus on the burden and available treatment for childhood cancers.
The unique epidemiological characteristics of childhood cancers make a strong case for studying them separately from adult cancers. The most striking difference perhaps is that cancer is generally a rare disease among children – annual incidence of all cancer in children under 5 years of age in developed countries is only 0.5% (1). Moreover, adult cancers are associated with modifiable risk factors, whereas childhood cancers are not. Consequently, population based screening and prevention programs are not the best recourse for pediatric cases, which benefit instead from accurate early diagnosis and effective treatment (10).
When the data on pediatric cancer is stratified by geographic location, the highest incidence of childhood lymphomas occur in North Africa and the Middle East, while leukemia accounts for a quarter of childhood cancers in the region (2).
There have been major advances in cure rates for childhood cancer in the Western world; however, these improvements have not translated to low-and-middle-income countries (LMICs) in MENA and around the world, where youth account for a large proportion of the population.
Availability of data and research
In general, there seems to be very limited information and research on the burden of pediatric cancer in the Middle East. A review of the PubMed database yielded only 6 relevant journal articles published in the past 10 years.
Even a quick glance through the cancer registry list that informs the International Incidence of Childhood Cancer series displays the scarcity and inconsistency of data reported from Middle Eastern countries’ cancer registries, the inadequacies of which have been discussed in a previous blog post.
In lieu of the establishment of high-quality population-based cancer registries with disaggregated data on childhood cancer, instituting the mandatory registration and reporting of pediatric cancer cases is essential to establish the regional incidence of childhood cancers to inform policy and resource allocation.
Regional access to pediatric oncology care
In 2005, six participating countries in the Middle East Cancer Consortium (MECC) assessed the availability of resources and services for pediatric patients. They reported that services were very limited and that outcomes were worsened by the simultaneous lack of psychosocial support for the needs of the child and the family (1).
Figure 1: Pediatric supportive and palliative care provision in six MECC countries (1).
|Pediatric Services||Pediatric Unit||Pediatric Hospital Support||Pediatric Home Care||TOTAL|
Since then, the Children’s Cancer Hospital Egypt “57357” has been built and is currently the world’s largest pediatric cancer hospital. Since its opening six years ago, the cure rate for childhood cancer has increased to 70-90%. The hospital is affiliated with Boston Children’s hospital, which provides training for medical professionals in Egypt and has significantly contributed to the improvements in quality of care.
The Avicenna Project based at Imperial College is in the process of constructing a state of the art pediatric cancer hospital in Rafsanjan, a province in the city of Kerman, Iran to address the incidence of pediatric cancers, which are second only to rates in the capital Tehran. In Rafsanjan’s main hospital there are 14 pediatric specialists, 1 pediatric cardiologist and 1 pediatric surgical specialist. At the moment, there is no specialized center in Rafsanjan that offers care or treatment to cancer patients, adults or children (6). Avicenna will require tremendous local and international support to make sure their goals are met.
Some countries, like Yemen, lack essential diagnostic and therapeutic services that should be available for pediatric oncologists (4).
In Iraq, less than 10% of Iraqi children survive their disease. The US Army Corps of Engineers has helped establish better diagnostic services at Basrah’s Children Hospital; however, the impact of war has continued to have adverse affects on the Iraqi health system, described in detail in a recent Nature Middle East article. The findings from research on the use of depleted uranium and its exposure has been associated with malignancies in Iraqi children that have not been seen since the previous Gulf wars (5).
Other hospitals in Iraq, like Baghdad’s Children Welfare Teaching Hospital, operate below standard on many levels. This particular hospital faces challenges such as drug shortages, limitation of diagnostic facilities, lack of infection control and pain management (8).
Jordan does not have a pediatric oncology hospital, and care is delivered through larger cancer centers and pediatric hospitals. The standard treatment guidelines for patients are ones used in the US or UK which might be different for this particular context, suggesting the need for culturally-specific guidelines (7).
Future directions – Information for advocacy
The example of Egypt’s “57357” hospital shows the feasibility of improving pediatric cancer cure rates with targeted resources and infrastructure.
To facilitate improvements elsewhere in the region requires improved data on incidence and evidence on the cost-effectiveness of treatment as a first step to advocating for the resources and attention to achieve better care.
Building political commitment for improved cancer care is tied to raising public awareness of the disease and providing accurate information to enable patient and community advocacy.
A successful example of broad advocacy at the international level is the International Society for Pediatric Oncology, @WorldSIOP, which works to improve childhood cancer treatment and has an active social media presence to share evolving research.
Social media has been successfully employed as a tool in the MENA region for disease advocacy and creating informed patient networks in other disease areas, @diabetesUAE for instance, and could be used to engage MENA stakeholders to build momentum and support for pediatric cancer care and treatment as the next child health priority.
- Freedman LS, Edwards BK, Ries LA. Cancer Incidence in Four Member Countries (Cyprus, Egypt, Israel, and Jordan) of the Middle East Cancer Consortium (MECC). ; Available from: http://www.seer.cancer.gov/archive/publications/mecc/mecc_monograph.pdf
- Stiller CA, Parkin DM. Geographic and ethnic variations in the incidence of childhood cancer. Br Med Bull. 1996;52(4):682–703.
- Collaborations in Psychosocial Care in Pediatric Oncology: The Middle East as a Case Example – Pediatric Psycho-Oncology: Psychosocial Aspects and Clinical Interventions, Second Edition – Shad – Wiley Online Library [Internet]. [cited 2014 Oct 6]. Available from: http://onlinelibrary.wiley.com/doi/10.1002/9781119941033.ch22/summary
- Ba-Saddik IA. Childhood cancer in Aden, Yemen. Cancer Epidemiol. 2013 Dec;37(6):803–6.
- Fathi RA, Matti LY, Al-Salih HS, Godbold D. Environmental pollution by depleted uranium in Iraq with special reference to Mosul and possible effects on cancer and birth defect rates. Med Confl Surviv. 2013 Mar;29(1):7–25.
- Jadali, F., Aghayan Golkashani, H., Habibi, G., Rouzrokh, M., Abdollah Gorji, F., Dini, F., Khodami, M., Nilipour, Y., Khaleghnejad Tabari, A. & Sadeghian, N. (2012) Survey on Childhood Solid Malignant Tumors in Cases Admitted to Mofid Pediatric Hospital From 1996-2010: a Single-Center Study . Iran J Cancer Prev. 5 (2), 93-104.
- Al-Rimawi, Hala Saleh. “Pediatric Oncology Situation Analysis (Jordan).” Journal of Pediatric Hematology/Oncology 34 (2012): S15-18. Web.
- Al-Hadad, Salma, and Mazin Faisal Al-Jadiry. “Future Planning to Upgrade the Pediatric Oncology Service in the Baghdad Children Welfare Teaching Hospital.” Journal of Pediatric Hematology/Oncology 34 (2012): S19-20. Web.
- Bhakta, N., A. L. C. Martiniuk, S. Gupta, and S. C. Howard. “The Cost Effectiveness of Treating Paediatric Cancer in Low-income and Middle-income Countries: A Case-study Approach Using Acute Lymphocytic Leukemia in Brazil and Burkitt Lymphoma in Malawi.” Archives of Disease in Childhood 98.2 (2013): 155-60. Web.
- Gupta S,Rivera-Luna R,Ribeiro RC, Howard SC (2014) Pediatric Oncology as the Next Global Child Health Priority: The Need for National Childhood Cancer Strategies in Low- and Middle-Income Countries. PLoS Med 11(6): e1001656. doi: 10.1371/journal.pmed.1001656