Childhood Cancer at the UCI: Burden and challenges

Summary presentation made by Dr. Joyce Balagadde Kambugu; Consultant paediatric oncologist, Head paediatric oncology, Uganda Cancer Institute at the 3rd Uganda Health Communications Network 26th -28th June 2019. The conference was themed around Non-Communicable Diseases; Communication, Myths, and Realities. Below Esther Nakkazi summarises Dr. Joyce Balagadde Kambugu presentation;

Status of cancer at UCI

• The number of new children has increased from 250 in 2013 to 582 in 2018 
• Acute leukaemia and lymphoma the most common cancers
• The prevalence of HIV is 6% 
• Kaposi's sarcoma (KS) is the most common HIV associated cancer
• Brain tumours are becoming increasingly common (5%)
• Rhabdomyosarcoma and wilms tumor are the most common solid tumours

Challenges of paediatric cancer care at the UCI
Insufficient Human resource
Misdiagnosis
Delayed presentation
Abandoned treatment
Lack of consistent adherence to treatment
Drug shortages
Treatment-related death
Use of reduced intensity treatment regimens to facilitate tolerability also contribute to treatment failure and excess relapse.

Ultimately these impact negatively on cure

A. Large Patient numbers
The service received almost 600 new patients from all parts of Uganda and parts of the neighbouring countries
Human resource and the infrastructure is strained
Increases risk of treatment abandonment
Increases risk of poor treatment adherence

This will partially be addressed by making operational the regional cancer centres: Mbarara,  Arua Mbale, Gulu
Improving psychosocial support
UCCF
Kawempe home care
Bless a child foundation

B. Late presentation
Early diagnosis of cancer is a fundamental goal
Allows an opportunity for timely treatment while disease burden is still in its earliest stages
Then prognosis may improve, and a cure can be attained with minimal side or late effects.
Delayed diagnosis is associated with more refractory disease and excess relapse
Increases the costs and morbidity of treatment and in turn, increases treatment abandonment

C. Drug shortages

1. Insufficient drug budget to purchase requisite quantities of drugs 
2. Stagnant drug budget despite increasing patient numbers 
3. 7B UGX from 2013/14 till 2017/18 when increased to 8.8B 
4. Currently, drug-availability is at 65% 
5. No access to newer more efficacious therapies with fewer side effects like the Mabs and Nibs 
6. Autonomy from NMS has afforded 2 things 
7. Optimizing of the available budget by enabling direct dealing with the manufactures; Norvatis, Sandos, Roche, Pfizer, Medac 
8. The unit cost of drugs came down so drug availability is now 65% from 30% 
9. The Institute is more in control of assurance of drug quality 

D. Treatment-related death (With compliments from Dr. Margaret Lubwama-Microbiology Phd student)

1. Sepsis 
2. Treatment regimens are intense 
3. Insufficient capacity to investigate 
4. Increasing prevalence of drug-resistant microbes 
5. Inadequate access to antimicrobials 

Access to blood products
UCI gets only 1/3 of requisite blood product demand even though UCI gets more blood products than any other Institution
Treatment-related marrow suppression
Sepsis (increases risk of bleeding)

Time period Jan 2018 to April 2019

Of 87 patients with haematologic malignancy with at least one episode of febrile neutropaenia 38 were paediatric
15 of the 38 children (39% ) had documented bacteremia
Of 22 gram-negative bacterial isolates from the 15 children, 16 (73 %) were multidrug resistant (to more than 3 classes) b-lactams, gentamicin, ciprofloxacin, carbapenems
Of the resistant bacteria l isolates (n=16 ) 50% (n=8) displayed the ESBL phenotype (were susceptible to carbapenems)

E. Need to use reduced intensity treatment regimes
To facilitate tolerability
Malnutrition and Sepsis contribute to treatment failure and excess relapse.
BL in HIC has a cure rate of almost 90% but with very high-intensity treatment regimens

The best survival rate in Uganda for BL is 50% at 2 years
This is the rationale for the rituximab clinical trial that is starting at the UCI in paediatrics in 2020/2021