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Highlights from the 13th African Continental Meeting of the International
Society of Paediatric Oncology (SIOP), 6–9 March 2019, Cairo, Egypt
Elhamy Rifky Khalek1, Glenn M Afungchwi2, Mohamed El Beltagy3, Ndagire Mariam4, Hoda Zaki5, Trijn Israels6, Elizabeth Molyneux7,
Scott C Howard8, Catherine Patte9, Judy Schoeman10, Elena Ladas11, Mohamed S Zaghloul12, Yasser S ElDeen13, Soha Ahmed14,
Sherif Kamal15, Eric Bouffet16, Kathy Pritchard-Jones17 and Laila Hessissen18
1 Professor of Paediatric Oncology, Faculty of Medicine, Zagazig University, Children’s Cancer Hospital Egypt 57357, Cairo 11617, Egypt
2Manager,CameroonBaptistConventionHealthServicesChildhoodCancerProgramme,CameroonUniversityofStellenbosch,Stellenbosch7602,SouthAfrica 3 Professorofneurosurgery,FacultyofMedicine,CairoUniversity,KasrElAini,Cairo,andHeadofNeurosurgery,Children’sCancerHospitalEgypt57357, Cairo 11617, Egypt 4 Nursingofficer,UgandaCancerInstitute,Kampala,POBox3935Uganda 5 Dean,FacultyofNursing,HelwanUniversity,ModernUniversityforTechnologyandInformation(MTI),Cairo,Egypt 6 PrincessMàximaCenterforPediatricOncology,3584CSUtrecht,TheNetherlands 7 PaediatricDepartment,CollegeofMedicine/QueenElizabethCentralHospital,Blantyre,Malawi 8TheUniversityofTennesseeHealthScienceCenter,Memphis,TN38163USA 9 CLCCGGroupeFranco-Africaind’OncologiePédiatrique(GFAOP),InstitutGustaveRoussy,FranceandGFAOP,94800Villejuif,France 10 Chiefdietician,DepartmentofPaediatricsandChildHealth,StellenboschUniversity,CapeTown7530,SouthAfrica 11 AssociateProfessorforGlobalIntegrativeMedicine,Director,IntegrativeTherapiesProgram,ColumbiaUniversityMedicalCenter,USA 12 ProfessorofRadiationOncology,NationalCancerInstitute;Chair,RadiationOncologyDepartment,Children’sCancerHospitalEgypt57357,Cairo,Egypt 13 ProfessorofPediatricSurgery,AlexandriaUniversity,Alexandria21568,Egypt 14 Chairman,ClinicalOncologyDepartment,AswanUniversityandConsultant,Children’sCancerHospitalEgypt57357,Cairo,Egypt 15 Director,DepartmentofPharmaceuticalServices,Children’sCancerHospitalEgypt57357,Cairo,Egypt 16 President,InternationalSocietyofPaediatricOncology(SIOP),ProfessorofNeuro-oncology,SickChildren’sHospital,TorontoONM5G1X8,Canada 17 SIOPPresident-elect,ProfessorofPaediatricOncology,UCLGreatOrmondStreetInstituteofChildHealth,UniversityCollegeLondon,LondonWC1E 6BT,UK 18SIOPAfricaContinentalPresident,ProfessorofPaediatrics,PediatricHaematologyandOncologyCenter,UniversityMohamedVRabat,RabatBP.8007. UN,Morocco Correspondence to:ProfessorElhamyRifkyKhalek Email: elhamyrifky@yahoo.com ecancer 2019, 13:932 https://doi.org/10.3332/ecancer.2019.932 Published:28/05/2019 Received:10/04/2019 Publicationcostsforthisarticleweresupportedby the ecancerGlobalFoundation.
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Abstract
The13thAfricancontinentalmeetingoftheinternationalsocietyofpaediatriconcology, held on 6–9 March 2019 in Cairo, was organised in collaboration with the Children CancerHospital(57357)inEgyptandtheglobalparents’organisation(ChildhoodCancer International)andsupportedbyalargeinternationalfaculty.With629delegatesfrom 37countries(24African),thiswasthelargestforumofhealthcareprofessionalsfocused onchildrenandyoungpeoplewithcancerinAfricatoshowcaseadvancesanddiscuss furtherimprovements.Threetargetedworkshops,onnursingcare,pharmacyandnutri-tion,attractedlargenumbersandcatalysednewcollaborativeinitiativesinsupportive care studies, extended roles for pharmacists in quality control and care delivery and addressed malnutrition concurrently with cancer treatment. The Collaborative Wilms TumourAfricaProject,openinsevensub-Saharancountries,andthetrialsinBurkitt’s lymphomareportedencouragingoutcomeswithfurtherinitiativesinsupportivecare(the supportivecareforchildrenwithcancerinAfricaproject).Whileacknowledgingdeficitsin radiotherapyprovision,availableinonly23of52Africancountries,centreswithfacilities reported their technical advances that benefit patients. Of great importance for chil-drenwithbraintumours,whoareunderdiagnosedinAfrica,wasthefirstannouncement
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Introduction
SuccessfultreatmentofchildhoodcancersinAfricaisofincreasingimportanceduetothehighproportionofchildrenandadolescentsinthe Africanpopulationandthecontinuousdecreaseindeathratesfromothercauses[1] .This13thbiannualcontinentalmeetingoftheinter-nationalsocietyofpaediatriconcology(SIOP),inconjunctionwithAfricanrepresentativesfromparents’organisations[ChildhoodCancer International(CCI)]andtheChildren’sCancerHospital(57357)inEgypt(CCHE),Cairo,aimedtoshowcaseprogressinthisfieldacross multipledisciplinesandreceived340abstractsfrommorethan33countries,manydescribingverypositiveprogressthroughcollaborative prospective clinical research [2].DelegateswerewelcomedtothecongressbyProfElhamyRifkyA.Khalek(PresidentoftheConferenceandthehostoftheevent),ProfLaila Hesssissen,PresidentofSIOPAfricaandthemembersoftheLocalOrganisingCommittee.ProfRifkywelcomedtheparticipantsandgave abriefsummaryofthecongressandtheschedule.Thecongresswasattendedbyatotalof629delegatesfrom37countries(24African), including 156 paediatric oncologists, 53 paediatricians, 32 radiotherapists, 27 surgeons, 92 nurses, 59 pharmacists, 14 diagnostic services (includingninepathologists),102nutritionistsand38parents.Scholarshipswereavailablefor156medicalandnursingdelegates,forwhich supportfromSanofiEspoirFoundation,CCI,CCHE(57357),EgyptianNationalCancerInstitute,MinistryofPublicHealth, Pfizer Pharmaceu-ticals,NewBridgeandAbbottNutritionisacknowledged. ProfessorSherifAboulNaga(CCHE,Cairo,Egypt)describedintheopeningceremonyhowtheCCHE57357(CCHE,widelyknownasHos-pital57357)wascreated,inspiredbythemodeloftheSt.JudeResearchHospitalinMemphis.ThepeopleofEgyptandfriendsfromallover theworldandmostparticularlyintheArabWorldgenerouslycontributed,anditwasbuiltcompletelybydonations.Thehospital’smission istoprovidethebestcomprehensivefamily-centredqualitycareandachanceforcuretoallchildrenwithcancerseekingitsservices,free ofchargeandwithoutdiscrimination.Itopenedin2007with179bedsand,by2018,hadgrownto320bedsandhasover15,000patients underactivetreatment.Ithasallthe‘state-of-theart’clinicalfacilities(includingtwolinearacceleratorswithplansforprotonbeamtherapy) andcomprehensivesupportservices,in-houseschoolingandchildlifeandplay.Sinceitsinception,theCCHEleadershiprealisedthatcarrying outresearchinmedicalandnon-medicalareaswasaprerequisitetoprogressinachievingcuresandabetterfutureforchildrenwithcancer. Hence,theadoptionofanadvancedhealthinformaticssystem,whichenabledittobeapaperlesshospital,withthecompletedigitalisationof operational aspectsandacquisitionofastrongdatabase.Theymadeasignificantandtransformationalinvestmentinclinicalpharmacystaff andprocesses.Heemphasisedtheimportanceofinvestinginpeople,withallstaffgiventimeforandexpectedtocontributetoresearchand education.Leadershiptrainingandembeddingkeyperformanceindicatorsatalllevels,withregulartargetedfeedbacktodepartmentsand teams,haveenabledtheorganisationtomakeremarkableprogressinimprovingsurvivalratestoanestimated73%averageoverallsurvival rate for those treated today.
Oneofthebiggestbarriersfordelegateswhowishedtoattendwasobtainingavisainatimelyfashion.Ofthe33participantsaffected,some ofwhoseworkhadbeenselectedforprizeconsideration,only22wereabletoobtainavisaontimetoattend.Visaswereonlyissuedafter personalinterventionsbythelocalorganisingcommittee,addingconsiderablytotheadministrativeburdenoforganisingaclinicalconfer-enceinAfrica.Thisissueneedstobeconsideredbybothfuturedelegatesandconferenceorganisers,toensuretimelysharingoflearningto benefitchildrenwithcancerandthehealthcareprofessionalswhocareforthem. ofAfricanpaediatricneuro-oncologysociety,whose63currentmembersaimtotackletheshortageofneurosurgeonsthroughtraining fellowships,workshopsandadedicatedconference.ThecongressprovidedtheopportunitytodiscusshowAfricancountrieswillworkwith theWHOglobalinitiativeaimingtoimprovechildhoodcancersurvivalto60%inallcountriesby2030.Thisconferencereportisdedicated tothethreeKenyandelegateswhodiedtragicallyontheEthiopianAirlinesflightET302ontheirwayhome,fullofnewideasandpridein whattheyhadachievedsofar.Allthosewhoheardtheirpresentationsaredeterminedtocontinuetheirexcellentworktoimprovecancer careforchildreninAfrica.
Con fer enc e R eport Theprogrammecoveredalmostallaspectsofchildhoodcancercare,fromimprovingdiagnosistodeliveringsuccessfultreatmentadapted totheavailableresources.Theimportanceofworkingcollaborativelyandinvolvingparentstodefineneedswasemphasisedtodemon-stratethat,eveninthemostresource-challengedsettings,progressinsurvivalratesandqualityofcarecanbeachievedthroughtargeted interventions(Figure 1). Threededicatedworkshopsinthekeyareasofnursing,pharmacyandnutrition,describedindetailinthefol-lowingsection,wereverywellattendedandfocusedonthespecificchallengesfacedbyAfricanchildrenwithcancerandthepaediatric serviceswhocareforthem.Thecongresshighlightedtheimpressiveprogressmadethroughprospectiveclinicaltrialsandstudiesand howthisresearchefforthasreapedwiderbenefitsforpaediatriccareandbuiltdurablecollaborativeresearchnetworks.Furtherinforma-tionisavailablefrom[2, 3].
Nursing workshop
ThenursingprogrammeatSIOPAfricaCairo2019comprisedtwofulldaysofworkshop,keynotelectures,free-papersessionsanddiscussions ofcollaboration,attendedbynursesfromsevencountries.AworkshoponnursingresearchwasdeliveredbyDrFaithGibson,laureateofthe SIOPNurselifetimeachievementaward2018.DrGibsontaughtthenursinggrouphowtoidentifyusefulresearchtopics,varioustypesof quantitativeandqualitativeresearchmethodologiessuitableforansweringmultipleresearchquestionsandresearchstepsfromplanningto thedisseminationoffindings.Nursesexpressedseveralareasofresearchpriorities,alistofwhichwascollatedforfurtherexplorationwithin the group.Figure 1. Cause-specific interventions to reduce treatment failure for children with cancer in low- and middle-income countries. (Used with the permission of Scott C Howard, MD, MSc.)
Con fer enc e R eport Threekeynotelecturesweredelivered.ProfNagwaElkhatebfromEgyptemphasisedtheimportanceofpainassessmentusingculturally andage-appropriatetools,followedbythemeticulouspharmacologicalornon-pharmacologicalintervention.SrRachelHollis(LeedsHos-pitalsNHSTrust,UK)gaveakeynotelectureontheSIOPPaediatricOncologyinDevelopingCountries(PODC) nursingbaselinestandards forlow-andmiddle-incomecountries(LMICs)andadvocacy.Thesesixstandardsforqualitynursingcareincludestaffingbasedonpatient acuity;formalorientationprogrammes;continuouseducation;recognitionofnursesasintegralmembersofthemultidisciplinaryteams; resourcesforsafecare;andresearchforevidence-basednursingpractise[4] .Arecentsurveyshowedthatthedisparitiesintheattain-mentofthebaselinestandardswithLMICswerelargelydisadvantaged[5].AnadvocacytoolkitforthesestandardsisavailableontheSIOP website[6] .ProfZeinabLotfy(ModernUniversityforTechnologyandInformation,Cairo,Egypt)ofEgypttalkedabouttheessenceofcom-municationskillsinnursingeducation,highlightingtheneedfortheconsiderationoflocalculturalrealitiesinimportantaspectsofnursing caresuchasbreakingbadnewsandeducatingchildrenandfamiliesontheirtreatment. Therewere11freepapers,threeofwhichwererecognisedfortheirqualityandrelevance.JoanNakabiri(UgandaCancerInstitute,Kampala, Uganda)fromUgandapresentedonhowacontinuousnurse’seducationprogrammehasincreasedtheknowledgeandconfidenceofpaedi-atriconcologynursesattheUgandaCancerInstitute.HanyEskanderfromCCHEwasrecognisedforanassessmentofintensivecarenurses’ knowledgeandpractisesregardingutilisationofinfectioncontrolstandardswhichshowedapositivecorrelationbetweenknowledgeand practise of infection control [7].Herecommendedcontinuouseducationonthelatestevidence-basedinfectioncontrolpractises.Finally, VeraNjamnshi(CameroonBaptistConventionHealthServices,Cameroon)fromCameroonwasrecognisedforpresentingonthecontribu-tion of the nurses’ role in planning, patient follow-up, informed consent and data collecVeraNjamnshi(CameroonBaptistConventionHealthServices,Cameroon)fromCameroonwasrecognisedforpresentingonthecontribu-tion for assessing the fertility of long-term female Burkittlymphomasurvivors. Collaborationwasoneofthecentralthemesofthenursingprogramme.Inordertofacilitatecommunicationandsharingofknowledgeand initiativein-betweenconferences,thenursesdecidedtocreateSIOPAfricanursingWhatsAppandFacebookgroups.Anevaluationform completedbymostparticipantsshowedthattheyweresatisfiedwithitsvariouscomponents.Afewsuggestionsforfuturemeetingswere:to includemorecontentrelatedtopalliativecareandpsychosocialsupport,toarrangesittinginaU-shapeforbetterinteractionandtoallocate moretimeforgroupwork.
Clinical pharmacy workshop
ForthefirsttimeinAfrica,aone-dayworkshopwasheldtobringtogetherallthoseworkinginclinicalpharmacyservicesandthoseprescribing chemotherapyforchildrenwithcancer.Sessionswereinteractivewithnetworkingresultinginseveralfuturecooperativeprojects—inparticu-lar,thosethatempoweredpharmacistsinAfricatoenhancetheirroletoimprovesafetyandefficacyoftreatmentforchildrenwithcancer andtouseresourcesmoreefficiently.DrSANaga,thefounderofclinicalpharmacyinEgypt,openedwiththehistoryoftheclinicalpharmacy concept,therecognitionofitsvalueandexamplesofpracticalimplementationinEgypt.KlausMeier(HKK(Heidekreis-KlinikumGmbHKran-kenhaus),Soltau,Germany),currentPresidentoftheEuropeanSocietyofOncologyPharmacy(ESOP),presentedtheESOP’splantodevelop oncology pharmacy practise over a period towards 2025, including the launch of a certification programme for Oncology Pharmacists compris-ing100hoursoftrainingincludingwebinarsandface-to-faceinternationalandnationaleducationalactivities.Hediscussedhowthecurrent ESOPprogrammeincludesoralchemotherapy,QUAPOS(oncologypharmacypractisestandards),thecontaminationproject,safehandlingand cleanworking,theessentialrequirementforoncologypractise,theEUSOPcertificationprogrammeand,finally,theECOPconferenceinMalta. BothspeakersurgedoncologypharmacistsinAfricatouniteandworktogethertoimplementthebestevidence-basedpharmacypractise. Thesurgicalsessionwaswellattendedbydifferentgenerationsofdifferentsub-specialtiesincludingpaediatricsurgeons,paediatriconcologists andpaediatricradiotherapistsfromdifferentinstitutesfromalloverEgyptaswellasdifferentAfricancountries.Thesessionwasalsoenriched byfruitfuldiscussionsfollowingeachpresentation.Oneofthemainrecommendationsduringthesediscussionswastoencouragemulticentric studiesandsurveyssuggestedbyphysiciansandresearchersinterestedincancerchildrenwithallofitsdifferentspecialtiesinEgypt.Itwas proposedthatafutureconferenceshouldensuregreaterattendancebyinternationalpaediatriconcologysurgicalfacultyfromtheInternational SocietyofPaediatricSurgicalOncology(IPSO).
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Nutrition workshop
MalnutritioniswidespreadamongchildrenlivinginAfricawithapproximately46%ofchildrendiagnosedwithcanceralsobeingdiagnosed with malnutrition [8].Managingmalnutritioncanbechallengingforpaediatriccancerunits(PCUs)withlimitedresources[9]; however, the clinicalimplicationsofnotremediatingmalnutritionleadstoreducedsurvivalandincreasedtreatment-relatedtoxicities[10]. On the final dayoftheconference,anutritionworkshopwasconvened,whichincludeddieticians,nurses,physicians,parentgroupsandnongovern-mentalorganisations(NGOs).DrElenaLadas(ColumbiaUniversity,USA)andDrRonaldBarr(McMasterUniversity,Canada)openedthe workshopwithpresentationsontheimpactofnutritionalstatusonsurvivalandoutcomeandtheimportanceofperformingsequential nutritionalassessmentsthroughouttreatment.Animportanthighlightwastheeaseanduseofmid-uppercircumference(MUAC)todeter-minenutritionalstatus.Regionaldataonnutritionalstatus,andbarrierstocare,wereprovidedbycliniciansinEthiopia(DrDanielHailu), SouthAfrica(JudySchoeman),Malawi(DrTrijnIsraels)andEgypt(DrSaharKhairy).Strikingfiguresontheratesofmalnutritionamong childrenwithcancerwerepresented;forexample,inMalawi,incidencereaches95%whenMUACortricepsskinfoldthicknessisutilised for nutritional assessment.LimitedaccesstonutritionalproductshasbeenreportedamongPCUinAfrica[9].MsBellaBerylJamona(HopeforCancerKids,Kenya) discussedthechallengescliniciansfaceinprovidingoptimalcaretoKenyanchildren.ProfMarianaKruger(TyerbergChildren’sHospital,Stel-lenbosch,SouthAfrica) (SouthAfrica)andDrLillianGesami-Steytler(Windhoek,Namibia)presentedonlimitedaccesstoenteralproducts andchallengesfacedwhenimplementingready-to-usetherapeuticformulas.Apersistentbarrierwasthepooravailabilityoftheseproducts inPCUsandthelackoftrainedpersonnelabletomanagechildrenwithcancerwhentheyalsohavesevereacutemalnutrition.Severalcase studiesillustratedvariedapproachestothedeliveryofnutritionalcareinalimitedresourcesettingbyDrSamerMohamed(CCHE,Egypt), DrJaneKaijage(TumainilaMaisha,Tanzania)andDrGeorge(CollegeofMedicine,Blantyre,Malawi).Forexample,cliniciansinTanzaniause home-madesmoothiesassupplementsduringcancercare,whereasMalawirelieduponsupplementsprovidedbytheacutemalnourished ward.Educationofstaffhasbeenreportedasabarriertonutritionalintervention[9] .TheInternationalInitiativeforPaediatricsandNutri-tion(IIPAN)hasestablishedanintensiveprogrammeinAfricatobegintoclosethisgapinclinicalcare.HappinessNdifon,anutritionistfrom CameroonBaptistConventionHealthServices,Cameroon,presentedhowshehadimplementedanutritionprogrammeinCameroonafter attendinga2-weekintensivetrainingcourseatanIIPANtrainingsite(SouthAfrica). Finally,theoncologyteamfrom57357Children’sHospitalinEgyptpresentedonthecentre’sresearch.Topicsincludedtheroleofnutritional therapyandsensitisationtoradiotherapy(DrAhmedEl-Saka),highaflatoxinsinEgyptianfood(DrAfafAmin)andtheimportantroleof breastfeedingaspartofimmunomodulatorytherapy(GihanFouad). Inconclusion,theworkshopestablishedthatthereisaneedforcollaborative,prospectivestudiesonnutritionalstatusinPCUinAfricaand, byincludingMUAC,standardisedassessmentcanbeachieved.Educationofstaffmembersandsynergyamongnutritionalgroupswithin hospitals,particularlywithexistingmalnutritionclinics,isapressingneedforPCUinAfrica.Moreover,PCUneedfinancialandproductsup-porttobeabletoincreasenutritionalinterventions.TherequestforsimilarworkshopstoimprovenutritionalcareintheirPCUinfuture yearswasreceived,withthefirstworkshopplannedinKenyaandsubsequentplansforthenextSIOPAfricacongresstobeheldinKampala, Uganda, in 2021.
Progress in optimising management of the most curable childhood solid tumours
Burkitt’s lymphoma
CatherinePatte(InstitutGustavRoussy,France)reportedthelatestresultsoftheinternationalintergrouprandomisedtrial,the‘Inter-B-NHLRitux2010trial,’runineightEuropeancountries,Australia,Canada,HongKongandtheUSA.Thisshowedthattheadditionof rituximabtoastandardbackboneofintensivechemotherapy(theLymphomesMalinsB(LMB)regimen)improvedevent-freesurvival (EFS) from84%to92%foradvancedstageB-celllymphomaandB-cellacuteleukaemia,anditisnowusedasastandardinhigh-income countries(HICs)[11].Althoughthelongertermimmunestatusofthesepatientsisstillunderevaluation,afewlong-lastingprofoundBCon fer enc e R eport immunodeficiencieshavebeenobserved.Hence,rituximabisnotcurrentlyrecommendedinadditiontochemotherapyinpatientswith low(stagesIandII)orintermediate(stageIIIwithlowlactatedehydrogenaselevel)stageswhohaveanEFS>97%withnoexpectedlate sequelaerelatedtochemotherapy.Inparticular,thebenefitofrituximabinsub-Saharancountries,wheremostchildrenaremalnourished andmoresusceptibletoinfections,mustbeevaluatedbeforerecommendingitsuse.CPattealsoreportedresultsofGFAOPstudies showingthatLMB-basedchemotherapyisfeasibleinsub-Saharancountriesandthatinitialdoseintensityiscrucial.HAbdelRahman (NationalCancerInstitute,CairoUniversityandCCHE,Egypt)showedinaprospectivestudyoffluorodeoxyglucosepositronemission tomography(FDG-PET)forassessmentofresidualmassesinmatureBcellnon-Hodgkinlymphomathatitisnotspecificenoughand recommendsthecontinuedneedforhistologicalconfirmationtoavoidunnecessarytreatmentescalation.DrJennyGeel(Universityof Witswatersrand,Johannesburg) describedeffortstoimproveoverallsurvivalforchildhoodcancerinSouthAfrica,acountrywith16.5 millionchildrenaged<15years.Theyaretakingadisease-by-diseaseapproachtoimplementaunifiednationaldiagnosticandtreatment protocol,aimingtoimprovesurvivalrates,decreasetoxicity,andunderstandandcontrolthecosts.ThefirsttumourchosenisHodgkin’s lymphoma.EMoussa(NationalCancerInstitute,CairoUniversityandCCHE,Egypt) developed the controversies in the treatment of HodgkinLymphoma.PostersreportedonNorthAfricansinglecentreresultinNHLandhigh-dose(HD),focussingonunusualsitesand causesoftreatmentfailures(toxicdeathsandmalnutrition).OneposteronBurkitthighlightedthebenefitofasecondpre-phasebefore startingtheinductionchemotherapy.AnotheroneconfirmedthevalueofPETaftertwocoursesofchemotherapyasapredictorofout-comeinHD.ProfPeterHesseling(StellenboschUniversity,SouthAfrica)presentedresultsindicatingariskofdecreasedfertilityingirls receivingimportantdosesofcyclophosphamideforthetreatmentofBurkittlymphoma.
Wilms tumour
Inthesessiononrenaltumours,ProfKathyPritchard-Jones(UniversityCollegeLondon,UK)gaveanupdateonoptimisationofclinicalrisk stratificationforthetreatmentofWilmstumour(WT)intheSIOPRenalTumoursStudyGroupnew‘UMBRELLA’protocolfollowingfurther analysesofthepreviousrandomisedtrialthathadrecommendedomissionofdoxorubicinfrompostoperativechemotherapyforallstage II/IIIintermediate-riskhistologyWTs[12].Pendingtheoutcomeofongoingmolecularbiomarkerresearch,focusedonthesomaticgainof chromosome1q,sheshowedevidenceforexcessrelapseintumourswithvolumegreaterthan500mLafterpre-operativechemotherapy, whenthehistologicalsubtypewasmixedorregressivesubtype.Itisnowrecommendedthatthesetumourscontinuetobetreatedwith doxorubicin included in postoperative chemotherapy[13]. Modest doses of doxorubicin are also now recommended for childrenwith micrometastasesvisibleonlyoncomputedtomography(CT).However,itisstillacceptabletodostagingusingachestX-ray,whichiswidely availableinLMICs.ThecollaborativeWTAfricaProject,presentedbyDrFrancineKouya(CameroonBaptistConventionHealthServices,Cameroon)hasimple-mentedanadaptedWTtreatmentguidelineinsub-SaharanAfrica,basedonSIOPRenalTumoursStudyGroup(RTSG) protocols, as a multi-centreprospectiveclinicaltrial.SevencentresinMalawi,Cameroon,GhanaandZimbabweareparticipating(Figure 2).Thecollaborative project’sprimaryaimsaretoimprovesurvivaltomorethan50%byreducingabandonmentoftreatmentanddeathduringtreatmenttobelow 10%.Aretrospective,baselineevaluationofendoftreatmentoutcomewasdonefora2-yearperiodpriortotheintroductionoftheguide-line.Comparedtothebaselineevaluation,abandonmentoftreatmentdecreasedfrom23%to13%(p=0.03)anddeathduringtreatment decreasedfrom21%to13%(N.S.).End-of-treatmentsurvivalwithoutevidenceofthediseaseincreasedinthefirst2yearsoftheproject from52%to68%(p=0.01)[14]. Thiscollaboration,usingrelativelysimpleandlow-costinterventionshasstrengthenedthelocalhealthcareteams’knowledgeanduseof sustainabletoolstodecreaseabandonmentoftreatmentandreducetoxicdeaths.Theincreaseinsurvivalwithoutevidenceofdisease attheendoftreatmentisexpectedtotranslateintoimprovedlong-termsurvival.Thegroupiscurrentlyanalysingthedataofthefirst 4yearsoftheprojectandpreparingtostartphaseIIoftheprojectinJanuary2020.Thisisexpectedtoincludesomemodifications topostoperativechemotherapyandauniformrelapsestrategy.Thegroupisalsodevelopingsupportivecareforchildrenwithcancer inAfrica(SUCCOUR),aprojecttoimprovesupportivecareforchildreninsub-SaharanAfrica.CentresinAfricawishingtojointhese projectsaremostwelcome.
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Figure 2. The Collaborative Wilms Tumour Africa Project brings together healthcare providers, hospitals, academic institutions, professional societies, and non-governmental organisations to improve cancer care and outcomes in several countries of Africa.
Supportive care for children with cancer in Africa
Improvedsupportivecarehasthepotentialtobenefitchildrenwithalltypesofcancerandthoseingeneralpaediatriccare.SUCCOURisa comprehensive,inclusiveprojectledbydoctorsandnursestopromoteimprovementsinsupportivecare.Itbuildsonthelessonslearntfrom theCollaborativeWTAfricaNetworkwithstep-by-stepdevelopmentandimplementationofsimple,effectiveandcost-effectivesupportive careinterventions,givingprioritytothosewiththehighestexpectedimpactonchildsurvival[15, 16](Figure 1).Eachsitefirstconductsa baselineevaluationofcurrentpractisesandoutcomesinseveralareasofsupportivecaresuchasfebrileneutropenia,nutrition,abandon-mentandtheuseoftraditionalmedicine.Gapsincareandbestpractiseswillbeidentifiedandaddressedthrougheducationalworkshops, advocacy, developing local appropriate supportive care guidelines, rigorous outcome evaluation and development of specific interventions basedonthecollectedlocalevidence.Itwillreferencethewell-developedframeworkforcause-specificinterventionstoreducetreatment failureforchildrenwithcancerinLMICs(Figure 1).
Prevention and management of toxicity associated with high-dose methotrexate
High-dosemethotrexate(HDMTX),definedasadosehigherthan500mg/m2,isusedtotreatarangeofadultandchildhoodcancers.Although HDMTXissafelyadministeredtomostpatients,itcancausesignificanttoxicity,includingacutekidneyinjury(AKI).AKIconstitutesanonco-logicemergencyinpatientsreceivingHDMTXbutcanbesuccessfullypreventedandmanagedeveninLMICs.Monitoringofserumcreatinine, urineoutputandserummethotrexateconcentrationisusedtoassessrenalclearance,withconcurrenthydration,urinaryalkalinisationand leucovorinrescue,topreventandmitigatetoxicity.MaintenanceofalkalineurinepHisespeciallyimportantbecauseitpreventsmethotrexate crystallisationintheurineandgreatlyreducestherateofmethotrexateentryintourothelialcells,thusprotectingthekidneybytwodistinct mechanisms.Wheremeasurement ofmethotrexate levelsisnotavailableornotavailablewithin aclinicallyuseful timeframe, successful
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managementofpatientsrequiringHDMTXtherapydependsonusingsomewhatlowerdoses(2–3g/m2insteadof5–8g/m2),meticulous measurementofurineoutputandmucosalerythema,preventionofvomiting,assuringnolossofIVaccessduringtheinfusionandfrequent measurementofcreatininetoallowrapidresponsetoanyincrease.ArecentstudyfromChandigarh,India,usedmethotrexate5g/m2 for chil-drenwithacutelymphoblasticleukaemia(ALL)inasettingwheretheycouldnotmeasuremethotrexatelevels.Usingextrahydration,close monitoringandfrequentchecksofurinepHandcreatinine,theydelivered100coursesofHDMTXwithoutworrisometoxicities[16, 17].
Importance of asparaginase in treating acute lymphoblastic leukaemia
ALLaffects120,000peopleeachyearworldwide,includingchildrenandadults.Itcanbepermanentlycuredmorethan80%ofthetime withtreatmentregimensthatcombineglucocorticoids,anthracyclines,vincristine,mercaptopurineandasparaginase[18].ScottHoward (UniversityofTennessee,Memphis,USA)discussedapproachestothemosteffectiveuseofasparaginase,whichrelyonminimisingthe
likelihoodofinitialallergicreactionsandhavingaccesstoatleastasecondformulationofthedrugforthosewhodoreact.NativeEsh-erichia coliasparaginase(Elspar,Leunase,Kidrolaseandothers)isontheWHOlistofessentialmedications,whileotherformulations,
currently PEGylated-E. coliasparaginase(Oncaspar),andErwiniaasparaginase(Erwinaze),assecond-lineasparaginaseforpatientswho develop hypersensitivity to E. coli asparaginases, are not.
Inrecenttimes,therehavebeenproblemsfeltaroundtheworldregardingtheavailabilityandaffordabilityofasparaginaseandquestion markshavebeenraisedaboutthequalityofsomesuppliers[1]. In HICs, PEG-E. coliasparaginaseisusedasfrontlinetherapybecauseitis long-actingandhaslowratesofhypersensitivity(10%–15%)andsilentneutralisingantibodyformation(1%)thannativeE. coli asparaginase. Most LMICs use the much cheaper native E. coliasparaginase,towhichallergicreactions(20%–42%ofpatientswithALL)andneutralising antibodyformation(inanother30%–40%)aremuchcommon.Thismeansthattwo-thirdsofpatientsdonotattaintherequiredasparaginase depletion unless they have access to a second asparaginase product, usually Erwinia asparaginase. Unfortunately, the supply of Erwinia asparaginasehasbeenlimitedtoHIC,andrecentshortageshaveaffectedpatientseveninHIC.Whennosecondproductisavailable,the inabilitytocompleteasparaginasetreatmentincreasestheriskofrelapse.Therefore,minimisationofallergicreactionstotheinitialformof asparaginase improves outcomes and reduces costs.
TherecentlypublishedUKALL2003trialusedPEG-E. coli asparaginase in a schedule that included several days of glucocorticoids prior to each dose of PEG-E. coliasparaginaseinthelow-riskandintermediate-riskpatients,whohada1%rateofallergicreactionandexcellent event-free survival [19].Patientsonthehigh-riskarmreceivedseveraldosesofPEG-E. coli asparaginase without preceding glucocorticoids andhadareactionrateof6%,suchthat,inthewholestudy,thereactionratewas2%[19].Thishasledtoanimmediatechangeinpractise, andmodificationofexistingprotocolstoincludeglucocorticoidsacoupleofdaysbeforeeachPEG-E. coli asparaginase dose, in the hope of reducingallergicreactionsto1%,thusallowingpatientstocompleteallasparaginaseandreducingtheneedforsecond-lineasparaginase (e.g.Erwinia).ProfHowarddiscussedfivestrategiestothechoiceoffirst-,second-andthird-lineasparaginase,andconcludedthatthemost clinically effective and cost-effective strategy is upfront use of PEG-E. coli asparaginase with second-line Erwinia asparaginase, when avail-able,inthe10%–15%ofpatientswhodevelophypersensitivity.TheaveragepatientwhoreceivesPEG-asparaginase1000–2500U/m2 has adequateasparaginaseactivityfor14–24days,adurationthatwouldrequirerepeateddosingofnativeE. coli asparaginase 2–3 times per weekduringthisinterval,oratotalof6–9doses,toachievecomparableasparaginaseactivity[20].
Information systems
Allstrategiestoreducetreatmentfailureforchildrenwithcancerdependonarobustinformationsystemtofacilitatecontinuous,relent-lessqualityimprovement.TheadvancedhealthinformaticssystemofCCHE,hospital57357,isnotaffordableinmostAfricansettings. AlternativesystemsadaptedtothepracticalchallengesfacedinAfricawerepresented.ProfScottHowarddescribedResonanceOncology (www.ResonanceOncology.org),anacademicallyled,cloud-based,cancerinformationsystem,availableatnocosttocentresinLMICs. Baselineriskassessmentforabandonmentcanbestoredintheoncologyadaptedresonancepatientcentre(RPC)abandonmentmodule andtheriskscorecalculatedthere.RPCcanalsocontainallthepatient’sclinicalinformation,chemotherapyroadmapandappointments,andservesasaunifiedsourceofinformationaboutthepatient’scareandoutcomes.Thesystemsupportsmultiplelanguages,andtheabil-Con fer enc e R eport itytoproduceanalyticsandvisualisationsinrealtimeallowssitestoquicklyandfrequentlyassessthecausesoftreatmentfailurebyregion, country, cancer centre, year of diagnosis or cancer type [21].Whencancerregistrydata,abandonmentriskfactors,treatmentappointment adherenceandoutcomes(causesoftreatmentfailure)arecollectedinrealtimeforallpatients,deploymentofinterventionscanbebased onlocalneedsandpriorities(Figure 1).Aprize-winningoralpresentationbyJeremieHassan(TumainilaMaisha,Tanzania)‘IncreasingSafety andConsistencyofChemotherapyTreatmentinResource-LimitedCountriesviaExcel-BasedPrescriptionAutomation’describedthework inMicrosoftExceltocreateprintablechemotherapyprescriptionsmartsheetsforcommonchildhoodcancer.Eightprotocolshavebeen fullyautomateduntilnow.Therewerehighlyinteractivediscussionswiththeaudiencewhofounditasaverygoodmethodtoreducetreat-ment errors that could lead to a greatly improved treatfullyautomateduntilnow.Therewerehighlyinteractivediscussionswiththeaudiencewhofounditasaverygoodmethodtoreducetreat-ment safely and efficiency.
Thesurgicalsessionwaswellattendedbydifferentgenerationsofpaediatricsurgeonsandothermedicalspecialitiesandemphasisedthe importanceofformalmultidisciplinarydiscussionwithoncologistsandradiotherapiststooptimiseindividualpatientcare.Amajorrecom-mendation was to promote the importance of involvement in multicentric studies and surveys. It was proposed that a future conference shouldbeorganisedwithalargerfacultyfromIPSO,theSIOPsurgeons.
Treatment of brain tumours in childhood
Theneuro-oncologysessionprovidedtheopportunitytoaddressthechallengesassociatedwiththedevelopmentofpaediatricneuro-oncologyprogrammesincountrieswithlimitedresources.Anumberoffactorsaffecttheseefforts,suchaslackofawarenessofpaediatric braintumours,latediagnoses,limitedimagingfacilities,absenceofpaediatricneurosurgicaltraining,lackofexpertiseinneuropathology, difficultiestoaccessradiationservicesandabsenceofmultidisciplinaryapproach.Severalsolutionshavebeeninvestigated,and,sofar, themostsuccessfulexperiencesarewiththedevelopmentoftwinningprogrammesbetweeninstitutionsinhigh-incomeandlow-income countries.Theuseofteleconferencesallowsface-to-faceinteractions,andregularreviewsanddiscussionsofchallengingcaseshavea majorimpactonclinicalpractise.
Inthiscontext,DrGiorgioPerilongo(UniversityofPadova,Italy) discussed the management of paediatric low-grade gliomas, reminding theaudiencethatthisconditionhasbeenlistedinthesixdiseasestargetedbytheWHOGlobalInitiativeforChildhoodCancer.Major advancesintheunderstandingofthemolecularbiologyofthisconditionhavehappenedduringthelastdecade,leadingtothedevelopment ofnewstrategiestargetingtheRAS/MAP-Kinasepathway.However,theseprogressesareunlikelytobenefitAfricanpatientsinthenear future,andthemanagementofAfricanpatientsshouldtakeintoaccountanumberoffactors,includingdistancefromthehospital,side effectsofchemotherapyandriskofabandonment.Inthiscontext,radiationmayhavestillanimportantrole,inparticular,whenconformal radiationisavailable.Themanagementofmedulloblastomaisfarmorecomplex,asitrequiresatimelyandmultidisciplinaryapproach. DrKieran(BostonChildren’sHospital,USA)reviewedtherecentprogressinthemanagementofthisconditionandaddressedthemain factorsofsuccesswhichincludeaccesstoapaediatricneurosurgeryfacility,timelyreferraltotheradiationoncologyunit,andadjuvant chemotherapyandfollow-upprovidedbyanexperiencedneuro-oncologyteam.DrBouffetprovidedanoverviewofpaediatriccancers associatedwithmismatchrepairdeficiency(MMRD),anoftenunder-recognisedconditioncloselyassociatedwithparentalconsanguinity. MMRDisnotexceptionalinAfricawhereconsanguinityiscommon.ChildrenwithMMRDdevelopmalignantbraintumours,lymphoma andcoloncancers.ThereisemergingevidencethatsomeMMRD-relatedsolidtumourscanbesuccessfullytreatedwithimmunecheck-pointinhibitors,andthemanagementofcancersassociatedwiththisconditionmayrequireaspecificapproach.DrZaghloulreportedon theongoingtrialofradiotherapyforpatientswithdiffuseintrinsicpontineglioma(DIPG),whichsuggeststhathypofractionatedradiation isgivenover13or15sessionsatadoseof3Gypersession(39or45Gy).Bothareequivalent(non-inferior)tostandardfractionation (54Gyin30fractions).Thisexperiencehascertainlyimportantimplications,inparticular,whenaccesstoradiationfacilitiesislimited.
Radiotherapy
IntheRadiationOncologysessionchairedbyJeannetteParkes(UniversityofCapeTown,SouthAfrica)andMohamedZaghloul(National CancerInstitute,CairoUniversityandCCHE,Egypt) eightimportanttopicswerediscussedexploringtheproblems,limitationandfutureCon fer enc e R eport ofradiationoncologyinAfrica.Parkes(SouthAfrica)presentedtheimportantissueoftheinterdependenceofradiotherapyandneuro-imaging,withtheneedforservicestokeepabreastofadvancesinimagingtoimprovethequalityandaccuracyofradiotherapy.Zaghloul (Egypt)presentedthesituationofradiationoncologyinEgyptandonthecontinentofAfrica.Thecausesofthedeficienciesinradio-therapyserviceavailabilitywerewidelydiscussedtogetherwiththesuggestedideastoimproveitslevel[22].Egypt,asanexample,could showcasetheimportanceofcollaborationbetweengovernmentalinstitutions,universities,NGOs,internationalbodiesandsocietieslike IAEA,ASTRO,ASCO,ESTRO,PROS(PaediatricRadiationOncologySociety)toimproveboththequantityandquantityofradiotherapy toserveAfricanpatients[23].DorraAissoui(HabibBourguibaUniversityHospital,Tunisia)presentedaprofileofthepositivechangesfor paediatricradiationoncologythathadoccurredinhercentreduring2010–16.Theimprovementsachievedareexpectedtoreflectupon survivalandqualityoflifeforthechildrentreated. SeveralpresentersfromEgyptdescribedclinicalandtechnicaladvancesintreatingpatientsattheircentres.SohaAhmed(AswanUni-versityandCCHE,Egypt)presentedtheexperienceatCCHEtosalvagechildrenwithrecurrentependymomaafterre-excisionofthe recurrence(orwithoutsurgery)throughreirradiation.ShesummarisedtheinternationalaswellasCCHEexperienceandconcludedthatit isnotonlyfeasiblebutalsobeneficialintermsofoverallsurvivalandprogression-freesurvival.EngySalah(CCHE)presentedtheexperi-ence of re-irradiation in DIPG patients in their first progression. Comparison of 27 re-irradiated patients with a retrospective matched cohortof27patientsreceivingbestsupportivecaredemonstratedsafetyandsuggestedefficacy.Furtherpresentationsdescribedanew technique,deepinspiratorybreathhold(DIBH)inmediastinalHodgkin’sLymphomainadolescents.HaythamShaheen(CCHE)presented afulldescriptionofthetechnique,itsscientificbackgroundandadvantageusingthenovelsurfacescan(Catalyst)togetherwithcone beamCT.Shaheenconvincedtheaudienceofthesimplicity,accuracyandefficiencyofthesystem.HanyAmmar(CCHE)comparedthe differentradiotherapytechniquesduringtreatmentwithDIBH.TheDIBHoffermuchsuperiordosimetricdistributionthanfreebreathing. Volumetricmodulatedarctherapywasshowntobemoreaccurateandtoprovideimprovedtumourcoveragewithreduceddosetosurrounding normalstructures,whilerequiringreasonablemonitorunitsandtimeonthemachinecomparedtointensity-modulatedradiotherapyand conformalradiotherapy.Finally,CarolineElmaraghy(CCHE,Egypt)presentedtheCCHEexperienceintreatingfocalbrainstemglioma.Ina retrospectivestudy,72patientsweretreatedeitherbycarefulwatching,chemotherapyorradiotherapyaccordingtocertaincriteriadepend-ingonsymptoms,site,sizeandprogressionofthetumour.Althoughthosewhoreceivedradiotherapyhadslightlybetteroverallsurvivaland progression-freesurvival,thedifferenceswerenotstatisticallysignificant.Theinteractionbetweentheaudienceandthespeakerswerehigh withexchangingideasandexperiences. ProfessorElBeltagy,professorofneurosurgery,CairoUniversityandHeadofNeurosurgery,CCHE,Egyptpresentedtherationaleforandthe officiallaunchoftheAfricanpaediatricneuro-oncologysociety(APNOS).Manyproblemsareencounteredinthediagnosisandtreatmentof childhoodbraintumoursinAfricaduetolackofresourcesandscarcityofappropriatelytrainedneurosurgeonsandotherphysicians.Thereis adeficiencyinpaediatricneurosurgeonsinAfricawithamediannumberofneurosurgeonsper100,000populationof0.01.Notonlyisthere asevereshortageoftrainedneurosurgeons,butalsoequipment,fundingandteachingprogrammes.Thesesignifypoorlydevelopedhealth systemsandunevendistributionofneurosurgicalandradiotherapyfacilitiesinmanycountriesandacrossthecontinent.Theconsequences arethehighmortalityandmorbidityratesseentodayfromconditionsrequiringneurosurgicalinterventions,withadelayindiagnosisand complicated clinical presentations.
Aftersuccessfulactivitiesoverthepast3years,includingworkshopsforneurosurgeryandtrainingprogrammesforAfricandoctors,the decisionwastakentoinitiatetheAPNOSandannounceitscreationduringtheSIOPAfrica2019conference.APNOSisaninitiativeto strengthencollaborationbetweenAfricancountriestoimprovediagnosisandmanagementofpaediatricbraintumoursbetweenexperts inneuro-oncologyandneurosurgeonsfrommanyAfricancountries.APNOShas63membersandboardmembersfromdifferentAfrican countries(Egypt,Morocco,Algeria,Tunisia,Libya,Sudan,Nigeria,ZimbabweandKenya).APNOSaimstobealeadingmodelofcollaboration towardsachildhoodbraincancer-freeAfrica,throughestablishing,facilitatingandsupportingthepaediatricneuro-oncologyservicesacross Africathroughcontinuoustraining,educationandcapacitybuildingtohelpalleviatethesufferingofAfricanchildrenwithbraintumours.The firstAPNOScongressisplannedforthefirsthalfof2020,tobeheldinCairo,Egypt,asthefirstofaseriesofplannedsemi-annualneurosur-geryworkshopsinEgypt,MoroccoandSudan,coveringdifferenttopicsincludinghydrocephalus,endoscopicsurgeryandtumoursurgeries. APNOSisalsosupervisingtheneurosurgicalfellowshipprogramme(CCHE-57357;starting2019).Inthefieldofradiationoncology,APNOS collaboratedwiththePaediatricRadiationOncologySociety(PROS)tohelptheimplementationofthefirstpracticalradiotherapycoursein
Con fer enc e R eport 2016(CCHE-57357),andcontinuestocollaborateonthemedicalbiophysicstrainingprogrammeandpreparationforthepaediatricmedi-calbiophysics57357fellowshiptogetherwiththeradiationoncologyfellowshipprogramme(CCHE-57357;starting2019).Thereisalsoan ongoingPaediatricOncologyfellowshipprogrammeforneuro-oncologytraining(currentlyongoingatCCHE-57357).Itisa30-monthfellow-shipprogrammeincollaborationwiththeDanaFarberCancerInstitute,includinga6-monthpaediatricneuro-oncologysubspecialtytraining. Throughthisprogramme,therearetwoAfricangraduatessofarfromEthiopiaandKenya.
Report of the joint session with parents
CCIAfricawasestablishedayearagoinJohannesburg,underthesupervisionofRuthHoffman,theCCIglobalpresident.TheSIOPAfrica congresswasthefirstmeetingheldinpartnershipwithCCIAfrica,withanintegrated‘parenttrack.’TheprogrammewasledbyRuthHoff-manandtheboardofCCIAfrica,whichhassevenmembersfromSouthAfrica,Zimbabwe,Uganda,Kenya,Nigeria,GhanaandEgypt,with CarlQueirosaselectedPresidentoftheCCIAfricanRegionalCommittee.Therewerepresentationsfromrepresentativesofparentgroups fromSouthAfrica,Zimbabwe,Nigeria,KenyaandtheAlexandriagroupofchildhoodcancercare(AGCCC)inEgypt.Threemembersof AGCCCpresentedontheEgyptianexperienceoffoundingthefirstsupportgroupforchildrenwithcancerandtheirfamiliesinAlexandria city,describinghowtheymobilisedallthepotentialpowersofthecommunityaswellasNGOstoestablishtheHospitalityHouseCaring forCancerChildren.Therewasaveryfruitfuldiscussionanddialoguebetweentwosurvivors:onefromKenya(MrSydney)andonefrom Cairo,Egypt(MrMahmoud).Overall,thisfirstjointsessionbetweenCCIAfricaandhealthcareprofessionalsinvolvedinSIOPAfricawasvery fruitfulandpointedthewayforotherregionstoachievebettercareandsupportforcancerchildrenandtheirfamiliesintheAfricansetting.
Conclusion
ThisSIOPAfricacongresshighlightedmanypositiveactionsinimprovingcareandsurvivalratesforchildrenwithcancerinAfrica.Itprovided animportantforumforpolicydiscussionswithWHOinrelationtotheirglobalmappinginitiativeofchildhoodcancerservices,thatcom-mencedwithAfricancountries.AllbutsixAfricancountriesresponded,butsomestatedtheyhavenospecificservicesforcancerinchildren andyoungpeople.WHO’s2015ambitionwastoreducedeathsfromfournon-communicablediseasesby25%.Cancerwasnotmentioned specifically,althoughitwasincludedintheoveralltarget.NowtheWHO2018GlobalInitiativeforChildhoodCancerhasaspecifictarget toimprovechildhoodcancersurvivalratesinallcountriestoatleast60%by2030.Thistargetistractablebytheknowledgewehavenow. Theconferenceshowcasedmanytwinninginitiativesthatwillcontributetosustainableimprovements,suchastheFrancophoneGFAOPthathas helpedtoestablish20childhoodcancerunitsin16countries,offersa1-yeardiplomacoursefromtheUniversityofParisSudandhastrained240 doctorsandnurseswhohavetreated>8,000children.ThebusinessmeetingofSIOPAfricahighlightedthatgovernmentsneedtolistentothe issuesandthepotentialsolutionsprovided—only18Africancountrieshavecancerplansidentifiedthroughthesurveyandonlysixmentionedthe specificneedsofchildrenwithcancer.Furthermore,theimportanceofpartnershipworkingwithparents’organisationscannotbeignored—while CCIAfricaisnowavisibleimprovementpartner,therearelargepartsofAfricawithoutparents’organisationregisteredwithCCI.TheSIOPAfrica 2019conferencehasprovidedmodelsolutionsthatnowneedtobeadoptedatscale.Wehopethatourgovernmentsarelistening! Asourclosingremarks,wewouldliketodedicatethisconferencereporttothreewonderfulhealthcareprofessionalsandhumanbeings,who losttheirlivesontheirwayhomefromtheconference,fullofnewideasandprideinwhattheyhadachievedsofar.Wehopethatallthose whoreadthisreportwillbeinspiredbytheirworkandwillcontinuetheirexcellentworktoimprovecancercareforchildreninAfrica.https:// siop-online.org/a-tribute-to-jayne-bella-grace/Acknowledgments
TheauthorswouldliketothankMsEsraaElHussienyforvaluableadministrativeassistance.Theauthorsthankalldelegatesfortheirpartici-pationandenthusiasmtobuildontheworkdiscussedduringtheconferenceanddescribedinthisreport.Con fer enc e R eport
Conflicts of interest
Allauthorsdeclarethattherearenoconflictsofinterestinrelationtothisarticle.Funding
Thisarticlereceivednospecificfunding.References
1. Lam CG, Howard SC, and Bouffet E, et al (2019) Science and health for all children with cancer Science 363(6432) 1182–1186 [doi:10.1126/science.aaw4892] PMID: 30872518
2. SIOP Africa conference website [http://siop-africa2019.com/] Date accessed 09/04/2019
3. Childhood cancer international–Africa website [https://www.childhoodcancerinternational.org/cci-global-network/africa/] Date accessed 09/04/2019
4. Day S, Hollis R, and Challinor J, et al (2014) Baseline standards for paediatric oncology nursing care in low to middle income
countries: position statement of the SIOP PODC nursing working group Lancet Oncol 15(7)681–682
5. MorrisseyL,LurveyM,andSullivanC,et al(2019)Disparities in the delivery of pediatric oncology nursing care by country income
clas-sification: international survey results Pediatr Blood Cancer 66(6)https://doi.org/10.1002/pbc.27663
6. SIOP basic nursing standards [https://siop-online.org/baseline-nursing-standards/] Date accessed 09/04/2019
7. EskanderHG,MorsyWYM,andElfekyHAA(2013)Intensive care nurses’ knowledge & practices regarding infection control standard
precautions at a selected Egyptian cancer hospital J Educ Pract 15
8. SchoemanJ(2015)Nutritional assessment and intervention in a pediatric oncology unit Indian J Cancer 52(2)186–190
9. SchoemanJ,LadasE,andRogersP,et al(2018)Unmet needs in nutritional care in African paediatric oncology units J Trop Pediatr https://doi.org/10.1093/tropej/fmy068
10. LadasEJ,AroraB,andHowardSC,et al(2016)A framework for adapted nutritional therapy for children with cancer in low- and
middle-income countries: a report from the SIOP PODC nutrition working group Pediatr Blood Cancer 63(8)1339–1348
11. Minard-ColinV,AuperinA,andPillonM,et al(2016)Results of the randomized Intergroup trial Inter-B-NHL Ritux 2010 for children
and adolescents with high-risk B-cell non-Hodgkin lymphoma (B-NHL) and mature acute leukemia (B-AL): Evaluation of rituximab (R) efficacy in addition to standard LMB chemotherapy (CT) regimen ASCO 10507–10507 [https://ascopubs.org/doi/abs/10.1200/ JCO.2016.34.15_suppl.10507]
12. Pritchard-JonesK,BergeronC,anddeCamargoB,et al onbehalfoftheSIOPRenalTumoursStudyGroup(2015)Doxorubicin omission
from the treatment of stage II–III, intermediate-risk histology Wilms’ tumour: results of the SIOP WT 2001 randomised trial The Lancet 386 1156–1164 https://doi.10.1016/S0140-6736(14)62395-3 [http://www.ncbi.nlm.nih.gov/pubmed/26164096]
13. vandenHeuvel-EibrinkMM,HolJA,andPritchard-JonesK,et al(2017)International society of paediatric oncology—renal tumour
study group (SIOP–RTSG). Position paper: rationale for the treatment of Wilms tumour in the UMBRELLA SIOP-RTSG 2016 protocol
Nat Rev Urol 14(12)743–752https://doi.10.1038/nrurol.2017.163
Con
fer
enc
e R
eport
15. IsraelsT,MolyneuxE,andtheSIOPAfrica–PODCCollaborativeWilmsTumourProjectGroup(2019)Lessons learned from a multicentre
clinical trial in Africa Nat Rev Clin Oncol 16 211–212 https://doi.10.1038/s41571-018-0121-0
16. DavidsonAandHowardSC(2018)Delivering modern anticancer therapies in low- and middle-income settings: we can be evidence
based Pediatr Blood Cancer 65 e27347
17. VaishnaviK,BansalD,andTrehanA,et al(2018)Improving the safety of high-dose methotrexate for children with hematologic cancers
in settings without access to MTX levels using extended hydration and additional leucovorin Pediatr Blood Cancer 65 e27241
18. PuiCH,YangJJ,andHungerSP,et al(2015)Childhood acute lymphoblastic leukemia: progress through collaboration J Clin 332938–2948 19. VoraA,GouldenN,andWadeR,et al(2013)Treatment reduction for children and young adults with low-risk acute lymphoblastic
leukaemia defined by minimal residual disease (UKALL 2003): a randomised controlled trial Lancet Oncol 14 199–209
20. VroomanLM,StevensonKE,andSupkoJG,et al(2013)Postinduction dexamethasone and individualized dosing of Escherichia Coli
L-asparaginase each improve outcome of children and adolescents with newly diagnosed acute lymphoblastic leukemia: results from a randomized study—Dana—Farber cancer institute ALL consortium protocol 00-01 J Clin Oncol 31 1202–1210
21. HowardSC,ZaidiA,andCaoX,et al(2018)The my child matters programme: effect of public-private partnerships on paediatric cancer
care in low-income and middle-income countries Lancet Oncol 19 e252–e266
22. BishrMKandZaghloulMS(2018)Radiotherapy availability in Africa and Latin America: two models of low/middle income countries
Int J Radiat Oncol Biol Phys https://doi.10.1016/j.ijrobp.2018.06.046
