Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

Hyperthermia: A Potential Game-Changer in the Management of Cancers in Low-Middle-Income Group Countries

Loco-regional hyperthermia at 40–44 °C is a multifaceted therapeutic modality with the distinct triple advantage of being a potent radiosensitizer, a chemosensitizer and an immunomodulator. Risk difference estimates from pairwise meta-analysis have shown that the local tumour control could be improved by 22.3% (p < 0.001), 22.1% (p < 0.001) and 25.5% (p < 0.001) in recurrent breast cancers, locally advanced cervix cancer (LACC) and locally advanced head and neck cancers, respectively by adding hyperthermia to radiotherapy over radiotherapy alone. Furthermore, thermochemoradiotherapy in LACC have shown to reduce the local failure rates by 10.1% (p = 0.03) and decrease deaths by 5.6% (95% CI: 0.6–11.8%) over chemoradiotherapy alone. As around one-third of the cancer cases in low-middle-income group countries belong to breast, cervix and head and neck regions, hyperthermia could be a potential game-changer and expected to augment the clinical outcomes of these patients in conjunction with radiotherapy and/or chemotherapy. Further, hyperthermia could also be a cost-effective therapeutic modality as the capital costs for setting up a hyperthermia facility is relatively low. Thus, the positive outcomes evident from various phase III randomized trials and meta-analysis with thermoradiotherapy or thermochemoradiotherapy justifies the integration of hyperthermia in the therapeutic armamentarium of clinical management of cancer, especially in low-middle-income group countries

Sequential improvement in paediatric medulloblastoma outcomes in a low-and-middle-income country setting over three decades

Background: Medulloblastoma (MB) is the commonest malignant brain tumour of childhood. Accurate clinical data on paediatric MB in the low-and-middle-income countries (LMIC) setting are lacking. Sequential improvements in outcomes seen in high-income countries are yet to be reflected in LMICs.

Aim: The aim of this study was quantification of paediatric MB outcomes in the LMIC setting over three decades of advances in multidisciplinary intervention.

Setting: Cape Town, South Africa.

Methods: This was a retrospective study of 136 children with MB diagnosed between 1985 and 2015. The modified Chang criteria were used for risk stratification. The primary objective of this study was overall survival (OS), quantified by analysis of epidemiological, clinical and pathological data.

Results: OS improved significantly during the most recent decade (2005–2015) when compared with the preceding two decades (1985–1995 and 1995–2005). Despite reduced-dose craniospinal irradiation (CSI) for standard risk cases, OS was significantly greater than during the preceding two decades. High-risk disease was identified in 71.4% of cases and was associated with significantly inferior OS compared with standard-risk cases. Improved OS was positively correlated with the therapeutic era, three-dimensional (3D) conformal radiotherapy technique, older age at diagnosis, classic and desmoplastic histology, extent of resection and absence of leptomeningeal spread on imaging.

Conclusion: Advances in multidisciplinary management of MB in our combined service are associated with improved survival. Access to improved imaging modalities, advances in surgical techniques, increased number of patients receiving risk-adapted combination chemotherapy or radiotherapy, as well as CSI using a linear accelerator with 3D planning, are considered as contributing factors.

Temporal trends in childhood cancer survival in Egypt, 2007 to 2017: A large retrospective study of 14 808 children with cancer from the Children’s Cancer Hospital Egypt

Childhood cancer is a priority in Egypt due to large numbers of children with cancer, suboptimal care and insufficient resources. It is difficult to evaluate progress in survival because of paucity of data in National Cancer Registry. In this study, we studied survival rates and trends in survival of the largest available cohort of children with cancer (n = 15 779, aged 0‐18 years) from Egypt between 2007 and 2017, treated at Children’s Cancer Hospital Egypt‐(CCHE), representing 40% to 50% of all childhood cancers across Egypt. We estimated 5‐year overall survival (OS) for 14 808 eligible patients using Kaplan‐Meier method, and determined survival trends using Cox regression by single year of diagnosis and by diagnosis periods. We compared age‐standardized rates to international benchmarks in England and the United States, identified cancers with inferior survival and provided recommendations for improvement. Five‐year OS was 72.1% (95% CI 71.3‐72.9) for all cancers combined, and survival trends increased significantly by single year of diagnosis (P < .001) and by calendar periods from 69.6% to 74.2% (P < .0001) between 2007‐2012 and 2013‐2017. Survival trends improved significantly for leukemias, lymphomas, CNS tumors, neuroblastoma, hepatoblastoma and Ewing Sarcoma. Survival was significantly lower by 9% and 11.2% (P < .001) than England and the United States, respectively. Significantly inferior survival was observed for the majority of cancers. Although survival trends are improving for childhood cancers in Egypt/CCHE, survival is still inferior in high‐income countries. We provide evidence‐based recommendations to improve survival in Egypt by reflecting on current obstacles in care, with further implications on practice and policy.

Barriers and facilitators to implementation of cancer treatment and palliative care strategies in low- and middle-income countries: systematic review.

To appraise improvement strategies adopted by low- and middle-income countries to increase access to cancer treatments and palliative care; and identify the facilitators and barriers to implementation.A systematic review was conducted and reported in accordance with PRISMA statement. MEDLINE, CINAHL, and the Cochrane Library databases were searched. Bias was assessed using the Standards for Quality Improvement Reporting Excellence, and evidence graded using the Australian National Health and Medical Research Council system.Of 3069 articles identified, 18 studied were included. These studies involved less than a tenth (n?=?12, 8.6%) of all low- and middle-income countries. Most were case reports (58%), and the majority focused on palliative care (n?=?11, 61%). Facilitators included: stakeholder engagement, financial support, supportive learning environment, and community networks. Barriers included: lack of human resources, financial constraints, and limited infrastructure.There is limited evidence on sustainable strategies for increasing access to cancer treatments and palliative care in low- and middle-income countries. Future strategies should be externally evaluated and be tailored to address service delivery; workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance.

Pilot study assessing the direct medical cost of treating patients with cancer in Kenya; findings and implications for the future.

Currently the majority of cancer deaths occur in low- and middle-income countries, where there are appreciable funding concerns. In Kenya, most patients currently pay out of pocket for treatment, and those who are insured are generally not covered for the full costs of treatment. This places a considerable burden on households if family members develop cancer. However, the actual cost of cancer treatment in Kenya is unknown. Such an analysis is essential to better allocate resources as Kenya strives towards universal healthcare.To evaluate the economic burden of treating cancer patients.Descriptive cross-sectional cost of illness study in the leading teaching and referral hospital in Kenya, with data collected from the hospital files of sampled adult patients for treatment during 2016.In total, 412 patient files were reviewed, of which 63.4% (n?=?261) were female and 36.6% (n?=?151) male. The cost of cancer care is highly dependent on the modality. Most reviewed patients had surgery, chemotherapy and palliative care. The cost of cancer therapy varied with the type of cancer. Patients on chemotherapy alone cost an average of KES 138,207 (USD 1364.3); while those treated with surgery cost an average of KES 128,207 (1265.6), and those on radiotherapy KES 119,036 (1175.1). Some patients had a combination of all three, costing, on average, KES 333,462 (3291.8) per patient during the year.The cost of cancer treatment in Kenya depends on the type of cancer, the modality, cost of medicines and the type of inpatient admission. The greatest contributors are currently the cost of medicines and inpatient admissions. This pilot study can inform future initiatives among the government as well as private and public insurance companies to increase available resources, and better allocate available resources, to more effectively treat patients with cancer in Kenya. The authors will be monitoring developments and conducting further research.