NEW PROJECTS

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NEW PODC PROJECTS/PROGRESS REPORTS
Chairman: HP Wagner

E. Ebeid reported on ALL treatment at the Menia Oncology Center (MOC), 300 km south of
Cairo (Childhood ALL in rural Egypt: facts/Cchallenges). MOC serves a rural population
of 4,3 millions (Egypt 2007: 75,5 millions, 57% rural, 29,5 millions below age 18). In the
Menia area the average daily income is 2-3 US$, the illitracy rate (15 years +) 45%. Since
most of the parents cannot afford to bring a child with cancer to the capital, MOC started to
treat these children, despite the lack of specialized PO residents (peditric oncologists from
Cairo attend twice weekly), nurses, lab and support facilities. Between 2000 and 2007 patients
with ALL were treated according to St. Jude’s total therapy protocols, mainly total 13A.
Diagnosis was based on morphology and cytochemistry only. Patients were considered low
risk, if the WBC was < 50x109/l, if no mediastinal mass, CNS disease or other leukemic
infiltration was present, and if the BM was in remission at day 15. No monitoring of MTX
levels. Therapy was often delayed or abandoned for financial reasons, repeated traumatic
punctures or ignorance. Of 100 newly diagnosed and treated patients, 46.5% survived eventfree
at 5 years (5 year EFS at NCI in Cairo: 62,5%). The 5 year OS was 48,5%.(low risk 60%,
high risk <40%). The cause of death in 40 patients who died for known reasons was relapse or
disease progression in 47,5%, abandonment of treatment in 30% and treatment related death
in 22,5%. This is an example of a level I PCU!

M. S. Pombo-de-Oliveira reported on Cancer incidence among children and adolescents
in Brazil: first report of 14 population-based cancer registries (Int J Cancer 2009: in
press). The 14 registries cover approximately 15% of the child and adolescent population.
During a time period varying from 3-5 years a total of 8222 cases were registered. The
number of registered cases varied from 29 to 3667, with a median of 426 per registry.
Considering only the 8 registries with 400 or more cases, the age-adjusted cancer incidence
rates (AAIR) per 1 million children 0-14 years old varied from 95 (Salvador) to 226 (Goiânia)
with a median of 178; for patients 1-4 years of age from 137 (Salvador) to 274 (Goiânia) with
a median of 227; and for15-19 years old from 84 (Salvador) to 264 (Sao Paulo) with a
median of 202. For different types of cancer the AAIR (ages 0-19) of registries with >400
cases were as follows: median (range): leukemia 48 (21-68), lymphoma 26 (14-34), CNS
tumors 26 (11-32), retinoblastoma 5 (2-7), neuroblastoma 9 (2-11), Wilms 9 (5-15) and bone
tumors 10 (8-18). The male/female ratio (age 0-19, registries with >400 cases) varied from
0.88 (Fortaleza) to 1.37 (Porto Alegre) with a median of 1.17.

G. Chantada summarized Preliminary results of a multicenter BFM-based study for Bcell malignancies in Central America. The use of NHL protocols from developed countries in resource poor countries is associated with a high treatment-related morbidity and mortality.
AHOPCA adapted therefore the treatment intensity of a BFM-based regimen according to the
risk of relapse using BFM risk groups by i)reducing the MTX dose in blocks A and B to 1 or
3 g/m2 in 3 h infusions, according to the patient’s risk; ii) reducing the ifosfamide dose by half
in block A; and iii)omitting block CC. All data were collected prospectively in
http://www.POND4kids.org. and all cases were presented weekly on http://www.Cure4kids.org for peer
discussions among Central Americn colleagues and external experts. From September 2004 to
February 2009, 114 evaluable patients (108 with Burkitt or Burkitt-like and 6 with large Bcell
lymphoma; 13 stage I-II, 86 stage III and 15 stage IV=mature B-ALL; median age 5.5
years) were treated. With a median follow-up of 24 months, the 2-year OS is 83% (SE 4%):
100% for stage I and II, 85% for stage III and 64% for stage IV. Seven patients died of
treatment-induced toxicity, 10 relapsed (5 died of disease, 1 abandoned and 4 are still alive)
and 8 abandoned therapy after 3-24 weeks. In conclusion survival has considerably improved,
but the toxic death and abandonment rates require further focused efforts.

T. Israels presented her Practical manual for the management of children with cancer
developed at and for the nurses, physicians and visitors of the SOBO pediatric oncology ward
of the Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi. One page is
devoted to the general approach to management (diagnosis, staging, safety of treatment,
treatment modalities and quality of life), 13 pages to the description of individual tumors
(Burkitt lymphoma, Wilms tumor, Hodgkin disease, NHL, acute leukemia, neuroblastoma,
rhabdomyosarcoma, retinoblastoma, hepatocellular carcinoma, osteosarcoma, germ cell
tumor, Kaposi sarcoma), one page to side effects of chemotherapeutic drugs, one to routine
investigations at admission and two to supportive care. The most interesting and helpful part
of the booklet is the appendix with 13 pages of treatment flow sheets allowing an easy
documentation of the treatment administered. As stated in the introduction: „We hope this
manual will help us to improve the treatment for children with cancer in Malawi. Clinicians
caring for children with cancer in settings similar to Malawi may use this manual at their own
responsability and clinical discretion“. A very helpful booklet indeed!

D.C. Stefan used a comparision of the childhood cancer incidence and outcome in Namibia
during the periods 1983-1988 and 2003-2009 to discuss the topic What is the way forward
in Africa?
Based on 163 cases observed during the first period, a minimum overall incidence of
55.5/million children less than 15 years) was calculated. The incidence (per million) of
leukemia (6.5), lymphoma (6.3) and CNS tumors (9.3) was considerably lower, the incidence
of renal tumors (7,4),malignant bone tumors (4.8) and soft tissue sarcomas (5.2) similar and
the incidence of retinoblastoma (5,8) higher than in Europe and North America (Wessels G,
Hesseling P: South African med J 1997;87:885-9).The calculated survival rates were as
follows: leukemia: 39%; lymphoma:53%; CNS tumors: 25%; neuroblastoma: 13%;
retinoblastoma: 46% and renal tumors: 73%, the projected 5 year survival rate of 150
evaluable cases was 37% (Wessels G, Hesseling P :Med Pediatr 1996; 27: 160-4).
During the second period 146 patients were recorded: 21% with leukemia, 18% with
retinoblastoma, 14% renal tumors and 13% lymphomas. In 2005 only 27% of 29 patients
survived for at least 1 year, but after reinstitution of a twinning program between Tygerberg
Children’s PO unit in Cape Town and the Katature Hospital in Windhoek, Namibia, the 1 year
survival rate increased to 45%.
Lessons learnt: Sustain twinning over long periods to improve survival and quality of life.
Establish a cancer registry (e.g. using http://www.POND4kids.org) to continuously assess incidence
and outcome. Recruit and train continuously PO personnel. Use regular telecommunications
to solve every-day problems. Develop palliative care.