SummaryCancer is now the second leading cause of death in the Caribbean. Despite this growing burden, many Caribbean small island nations have health systems that struggle to provide optimal cancer ...care for their populations. In this Series paper, we identify several promising strategies to improve cancer prevention and treatment that have emerged across small island nations that are part of the Caribbean Community. These strategies include the establishment of a Caribbean cancer registry hub, the development of resource-appropriate clinical guidelines, innovations in delivering specialty oncology services (eg, paediatric oncology and palliative care), improving access to opioids, and developing regional training capacity in palliative medicine. These developments emphasise the crucial role of public–private partnerships in improving health care for the region and show how fostering strategic collaborations with colleagues and centres in more developed countries, who can contribute specialised expertise and improve regional collaboration, can improve care across the cancer control continuum.
Background
The ongoing coronavirus 2019 disease (COVID‐19) pandemic strained medical systems worldwide. We report on the impact on pediatric oncology care in Latin American (LATAM) during its first ...year.
Method
Four cross‐sectional surveys were electronically distributed among pediatric onco‐hematologists in April/June/October 2020, and April/2021 through the Latin American Society of Pediatric Oncology (SLAOP) email list and St Jude Global regional partners.
Results
Four hundred fifty‐three pediatric onco‐hematologists from 20 countries responded to the first survey, with subsequent surveys response rates above 85%. More than 95% of participants reported that treatment continued without interruption for new and active ongoing patients, though with disruptions in treatment availability. During the first three surveys, respondents reported suspensions of outpatient procedures (54.2%), a decrease in oncologic surgeries (43.6%), radiotherapy (28.4%), stem cell transplants (SCT) (69.3%), and surveillance consultations (81.2%). Logistic regression analysis showed that at the beginning of the first wave, participants from countries with healthcare expenditure below 7% were more likely to report a decrease in outpatient procedures (odds ratio OR: 1.84, 95% CI: 1.19–2.8), surgeries (OR: 3, 95% CI: 1.9–4.6) and radiotherapy (OR: 6, 95% CI: 3.5–10.4). Suspension of surveillance consultations was higher in countries with COVID‐19 case fatality rates above 2% (OR: 3, 95% CI: 1.4–6.2) and SCT suspensions in countries with COVID‐19 incidence rate above 100 cases per 100,000 (OR: 3.48, 95% CI: 1.6–7.45). Paradoxically, at the beginning of the second wave with COVID‐19 cases rising exponentially, most participants reported improvements in cancer services availability.
Conclusion
Our data show the medium‐term collateral effects of the pandemic on pediatric oncology care in LATAM, which might help delineate oncology care delivery amid current and future challenges posed by the pandemic.
Survival rates for pediatric acute leukemia vary dramatically worldwide. Infections are a leading cause of morbidity and mortality, and the impact is amplified in low and middle-income countries. ...Defining the epidemiology of infection in a specific health care setting is paramount to developing effective interventions. This study aimed to define the epidemiology of and outcomes from infection in children with acute leukemia treated in a large public pediatric hospital in the Dominican Republic. A retrospective cohort was assembled of children newly diagnosed with acute leukemia between July 1, 2015 to June 30, 2017 at Hospital Infantil Dr. Robert Reid Cabral in Santo Domingo. Patients were identified from the Pediatric Oncology Network Database (PONDTM) and hospital admissions from the Oncology admissions logbook. Medical records and microbiology results were reviewed to identify all inpatient invasive infections. Distance from a child's home to the hospital was determined using ArcGIS by Esri. Infection rates were described in discrete time periods after diagnosis and risk factors for invasive infection were explored using negative binomial regression. Overall, invasive infections were common and a prominent source of death in this cohort. Rates were highest in the first 60 days after diagnosis. Gastroenteritis/colitis, cellulitis, and pneumonia were most frequent, with bacteremia common early on. Multidrug resistant bacteria were prevalent among a small number of positive cultures. In a multivariate negative binomial regression model, age ≥ 10 years and distance from the hospital > 100 km were each protective against invasive infection in the first 180 days after diagnosis, findings that were unexpected and warrant further investigation. Over one-third of patient deaths were related to infection. Interventions aimed at reducing infection should target the first 60 days after diagnosis, improved supportive care inside and outside the hospital, and increased antimicrobial stewardship and infection prevention and control measures.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Treating B–non‐Hodgkin lymphoma (B‐NHL) in lower‐income countries is challenging because of imprecise diagnosis, the increased risk of fatal toxicity associated with advanced disease at ...presentation, and limited supportive care.
Procedure
Central American patients with newly diagnosed stage I or II B‐NHL received a modified Berlin–Frankfurt–Münster (BFM) regimen including a prephase (prednisone, cyclophosphamide) followed by A/B/A courses (A: cytarabine, dexamethasone, etoposide, ifosfamide, methotrexate, and intrathecal therapy; B: cyclophosphamide, dexamethasone, doxorubicin, methotrexate, and intrathecal therapy). Those with stage III or IV NHL received additional courses (B/A/B), intensified for stage IV disease by additional vincristine and methotrexate doses. Patients in poor condition received a second prephase treatment before their chemotherapy courses.
Results
Between March 2004 and June 2016, of 405 patients with B‐NHL, 386 (109 females) were eligible for treatment. Immunohistochemistry was performed in 177 cases (47.4%) and characterized the disease as mature B‐cell lymphoma. Stage distribution was as follows: I/II, 31 (8.1%); III, 252 (65.3%); IV, 93 (24.1%); 10 (2.6%) not available. The 3‐year overall survival was 70% for the whole group (86% for stages I/II, 75% for stage III, 58% for stage IV). Events included death during induction (34 patients, 8.8%), relapse/progression (46, 11.9%), death in remission (9, 2.3%), second malignancy (1, 0.26%), and death of unknown cause (1, 0.26%). Twenty‐three (6%) patients abandoned or refused therapy.
Conclusions
Approximately 70% of children with B‐NHL from Central America experienced long‐term, disease‐free survival with a modified BFM schedule. Toxic death and relapse/resistant disease were the main reasons for treatment failure.
Palliative care offers children who have life-limiting and life-threatening oncologic illnesses and their families improved quality of life. In some instances, impeccable symptom control can lead to ...improved survival. Cultural and financial barriers to palliative care in oncology patients occur in all countries, and those located in Central America are no exception. In this article, we summarize how the programs participating in the Asociación de Hemato-Oncólogos Pediatras de Centro America (AHOPCA) have developed dedicated oncology palliative care programs. The experience in Guatemala, El Salvador, Costa Rica, Panama, Dominican Republic and Haiti is detailed, with a focus on history, the barriers that have impeded progress, and achievements. Future directions, which, of course, may be impacted by the COVID-19 pandemic, are described as well.
This report provides a summary of childhood cancer and the efforts made in the Dominican Republic to address child and adolescent cancer in line with the World Health Organization's Global Initiative ...for Childhood Cancer. Information was obtained by review of recent local and international literature on pediatric oncology. As a result of the Global Initiative, a meeting was held by the Council of Ministers of Health of Central America to support the development of national pediatric cancer plans for each country. The objectives of these plans are to improve overall survival and quality of care for children with cancer through early detection, diagnosis, and treatment. In the Dominican Republic, several steps have been taken in the past 5 years to enhance diagnosis and care of children with cancer. For example, the National Committee of Childhood Cancer, headed by the Ministry of Public Health and including relevant stakeholders, was established to develop the national childhood cancer plan. In addition, a campaign was launched to raise awareness of childhood cancer, and the first early detection manual and public policy on child and adolescent cancer were published. A government initiative has been working to improve the hospital infrastructure and expand the pediatric cancer center, and a national course on early detection of pediatric cancers has been held. In 2023, the National Strategic Childhood Cancer Plan 2023-2030 was launched in the Dominican Republic. The plan will help policy-makers, implementers, researchers, and advocates enhance diagnosis and care of children with cancer. Keywords Neoplasms; child; adolescent; public policy; quality of health care; Dominican Republic. En este informe se presenta un resumen del cancer infantil y las medidas adoptadas por Republica Domini cana para abordar el cancer en la poblacion infantil y adolescente en consonancia con la Iniciativa Mundial contra el Cancer Infantil de la Organizacion Mundial de la Salud. La informacion se obtuvo mediante el analisis de las publicaciones nacionales e internacionales recientes sobre oncologia pediatrica. Como resultado de la Iniciativa Mundial, el Consejo de Ministros de Salud de Centroamerica celebro una reunion para brindar apoyo a la elaboracion de planes nacionales sobre el cancer infantil para cada pais. Los objetivos de estos planes son mejorar la supervivencia general y la calidad de la atencion que se presta a la poblacion infantil con cancer mediante la deteccion temprana, el diagnostico y el tratamiento. En los ultimos cinco anos, Republica Dominicana ha adoptado varias medidas para mejorar el diagnostico y la atencion prestada a la poblacion infantil con cancer. Asi, por ejemplo, se creo el Comite Nacional de Cancer Infantil, encabezado por el Ministerio de Salud e integrado por las partes interesadas pertinentes, para elaborar el plan nacional sobre el cancer infantil. Ademas, se puso en marcha una campana de sensibilizacion sobre el cancer infantil y se publicaron el primer manual de deteccion precoz y la primera politica publica sobre el cancer en la poblacion infantil y adolescente. Mediante una iniciativa gubernamental se ha buscado mejorar la infraestructura hospitalaria y ampliar el centro de atencion a pacientes oncologicos pediatricos, al tiempo que se ha impartido un curso nacional sobre deteccion precoz del cancer infantil. En el 2023, Republica Dominicana puso en marcha el Plan Estrategico Nacional sobre Cancer Infantil 2023-2030. Este plan sera util a los responsables de la formulacion de politicas, las personas encargadas de su ejecucion, los investigadores y los promotores para mejorar el diagnostico y la atencion prestada a la poblacion infantil con cancer. Palabras clave Neoplasias; nino; adolescente; politica publica; calidad de la atencion de salud; Republica Dominicana. Este relatorio fornece um resumo sobre o cancer infantil e os esforcos da Republica Dominicana para enfren tar a doenca em criancas e adolescentes, em consonancia com a Iniciativa Global para o Cancer Infantil da Organizacao Mundial da Saude. As informacoes foram obtidas por meio de uma revisao da literatura local e internacional recente sobre oncologia pediatrica. Em consequencia da Iniciativa Global, o Conselho de Ministros da Saude da America Central se reuniu para apoiar a elaboracao de planos nacionais de cancer pediatrico para cada pais. Os objetivos desses planos sao melhorar a sobrevida global e a qualidade da atencao a criancas com cancer por meio de deteccao, diagnostico e tratamento precoces. Na Republica Dominicana, varias medidas foram tomadas nos ultimos cinco anos para melhorar o diagnostico e a atencao a criancas com cancer. Por exemplo, o Comite Nacional de Cancer Infantil, que e chefiado pelo Ministerio da Saude e inclui as partes interessadas pertinentes, foi criado para elaborar o plano nacional de cancer infantil. Foi lancada uma campanha de conscientizacao sobre o cancer infantil no pais. Alem disso, foram publicados o primeiro manual de deteccao precoce e a politica publica de cancer infantojuvenil. Uma iniciativa do governo vem trabalhando para melhorar a infraestrutura hospitalar e ampliar o centro de cancer pediatrico e ministrou um curso nacional sobre a deteccao precoce de canceres pediatricos. Em 2023, foi lancado o Plano Estrategico Nacional de Cancer Infantil 2023-2030 na Republica Dominicana. O plano ajudara formuladores de politicas, implementadores, pesquisadores e defensores da causa a aprimorar o diagnostico e a atencao a criancas com cancer. Palavras-chave Neoplasias; crianca; adolescente; politica publica; qualidade da assistencia a saude; Republica Dominicana.
Abstract
Background
The disparities in access to pediatric palliative care and pain management in Latin America remains an unaddressed global health issue. Efforts to improve the development of ...Palliative Care (PC) provision have traditionally targeted services for adults, leaving the pediatric population unaddressed. Examples of such services are scarce and should be portrayed in scientific literature to inform decision-makers and service providers on models of care available to tackle the burden of Pediatric Palliative Care (PPC) in Low-and middle-income countries (LMIC). The purpose of this study is to describe the implementation of a pediatric palliative care program, “Taking Care of You
” (TCY)
, in a tertiary care, university hospital in Cali, Colombia.
Methods
A program’s database was built with children between 0 to 18 years old and their families, from year 2017 to 2019. Descriptive analysis was carried out to evaluate the impact of the program and service delivery. A theory-based method was directed to describe the PPC program, according to the implementation of self-designed taxonomy, mapping theoretical levels and domains. Clinical outcomes in patients were included in the analysis.
Results
Since 2017 the program has provided PPC services to 1.965 children. Most of them had an oncologic diagnosis and were referred from hospitalization services (53%). The number of ambulatory patients increased by 80% every trimester between 2017 and 2018. A 50% increase was reported in hospitalization, emergency, and intensive care units during the same time period.
Conclusions
The program addressed a gap in the provision of PPC to children in Cali. It shows effective strategies used to implement a PPC program and how the referral times, coordination of care, communication with other hospital services were improved while providing compassionate/holistic care to children with life-limiting and threatening diseases and in end-of-life. The implementation of this program has required the onset of specific strategies and arrangements to promote awareness and education proving it a hard task, yet not impossible.
Pediatric Early Warning Systems (PEWS) aid in identification of deterioration in hospitalized children with cancer but are underutilized in resource-limited settings. Proyecto EVAT is a multicenter ...quality improvement (QI) collaborative in Latin America to implement PEWS. This study investigates the relationship between hospital characteristics and time required for PEWS implementation.
This convergent mixed-methods study included 23 Proyecto EVAT childhood cancer centers; 5 hospitals representing quick and slow implementers were selected for qualitative analysis. Semi-structured interviews were conducted with 71 stakeholders involved in PEWS implementation. Interviews were recorded, transcribed and translated to English, then coded using
and novel codes. Thematic content analysis explored the impact of
and
on time required for PEWS implementation and was supplemented by quantitative analysis exploring the relationship between hospital characteristics and implementation time.
In both quantitative and qualitative analysis, material and human resources to support PEWS significantly impacted time to implementation. Lack of resources produced various obstacles that extended time necessary for centers to achieve successful implementation. Hospital characteristics, such as funding structure and type, influenced PEWS implementation time by determining their resource-availability. Prior hospital or implementation leader experience with QI, however, helped facilitate implementation by assisting implementers predict and overcome resource-related challenges.
Hospital characteristics impact time required to implement PEWS in resource-limited childhood cancer centers; however, prior QI experience helps anticipate and adapt to resource challenges and more quickly implement PEWS. QI training should be a component of strategies to scale-up use of evidence-based interventions like PEWS in resource-limited settings.
The World Health Organization (WHO) designates early integration of palliative care as an ethical responsibility in the treatment of children with serious illness. Although structural barriers may ...influence provision of pediatric palliative care (PPC) for children with cancer in resource-limited settings, underlying physician perceptions may also impede early integration of PPC in cancer care.
To investigate perceptions among physicians in Latin America about the integration of palliative care for children with cancer.
This survey study used the Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey, which was developed for physicians who care for children with cancer and was initially distributed in Eurasia. The survey was modified for use in Latin America, including translation into Spanish and adaptation for cultural context. The survey was distributed between August 21, 2020, and January 31, 2021, to physicians treating children with cancer in 17 Latin American countries. Each country had a specific survey distribution method based on guidance of local experts.
The ADAPT survey evaluated physicians' understanding of palliative care principles, comfort in addressing patient and family suffering, and identification of barriers to PPC integration for children with cancer. Univariate and multivariable linear regression analyses were used to assess factors associated with physicians' knowledge about and comfort with PPC practice and whether independent physician variables were associated with survey response alignment with WHO guidance on PPC. Open-ended questions were analyzed qualitatively to supplement the quantitative data.
A total of 874 physicians from 17 countries participated, with an overall response rate of 39.9% (874 of 2193) and a median country response rate of 51.4% (range, 23.7%-100%). Most respondents were aged 35 years or older (577 66.0%), and 594 (68.0%) identified as female. Most physicians (486 55.6%) had no formal PPC training, and 303 (34.7%) had no access to PPC experts for consultation. Physician perspectives on PPC were generally aligned with WHO guidance (mean SD alignment, 83.0% 14.1%; range among respondents, 24.0%-100%). However, only 438 respondents (50.1%) felt comfortable addressing physical symptoms of patients receiving PPC, 295 (33.8%) felt comfortable addressing emotional symptoms, and 216 (24.7%) felt comfortable addressing grief and bereavement needs of the patient's family. A total of 829 participants (94.8%) desired further education and training in PPC.
Although physicians' perspectives aligned well with WHO guidance for PPC, this survey study identified opportunities for improving physician training in symptom management and emotional support for children with cancer and their families. These findings may inform the development of targeted interventions to improve the quality of PPC for children with cancer in Latin America.
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