Journal Issue: Vol.9, No.2 - April 2010

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Addressing Childhood Cancer in Resource Limited Countries: The Need for An International Collaborative Effort

Syed Rahman PhD Research Scientist, BC Cancer Agency, Canada Hamish Holewa BSc. Bed Grad Dip HEcon, Program Manager, International Program of Psycho-Social Health Research, CQUniversity, Australia With the intention of addressing the needs of children with cancer in Bangladesh, the British Columbia Cancer Agency, Canada, organised an international forum, bringing together key local decision makers and stakeholders from United Kingdom, Australia, Canada and Japan, with international childhood cancer specialists in a two day workshop, entitled 'Exploration and setting priorities for childhood cancer in Bangladesh'. The objective was to explore the incidence and nature of paediatric cancer within Bangladesh and design and implement research and intervention programs aimed at combating childhood cancer in this and other resource limited countries. The forum affirmed the need for progress and greater collaboration. Childhood cancer is a major health threat in developing countries. Globally, an estimated 250,000 children develop cancer each year, and 80% of them live in developing countries (BBC 2002, American Cancer Society 2007). Eight out of ten of the world's children diagnosed with cancer die without receiving treatment. Eighty percent are either not diagnosed or are denied potentially life-saving treatment (BBS 2002). Four in five are from low and middle income countries where child cancer is just one of many health priorities struggling for resources (World Child Cancer 2009). In resource limited countries, childhood cancer is often detected too late for effective treatment and appropriate treatment is often not available or affordable. Many children are never diagnosed at all, and when a diagnosis is made the treatment options may be limited (UICC 2006). The survival scenario in developed countries is quite different. Diagnostic and treatment protocols in developed countries have effectively improved childhood cancer survivorship by 75-80%. In developing countries, by sharp contrast, more than 80% of young cancer patients die (World Child Cancer, 2009). The childhood cancer situation in Bangladesh is similar to other developing countries. Cancer is one of the major causes of morbidity and the sixth leading cause of mortality in Bangladesh (MOHFW 2008; BBS, 2008). The annual incidence of paediatric cancer in Bangladesh is estimated to be 7000- 9000 cases per year; with less than 500 children receiving hospital treatment (Islam S 2009). Major disparities in access to very limited services between rural and urban areas are also distinctively visible. Most childhood cancer patients die without a proper diagnosis and adequate medical treatment, and more than half of properly diagnosed children still die within five years (MOHFW 2008). If diagnosed at an early stage, and if treatment is available, most childhood cancers are highly curable (Raul 2008). Using a Nominal Group Technique structured workshop, participants at the Childhood Cancer Forum were asked to decide on a recommendations for decreasing morbidity and mortality of paediatric cancer in Bangladesh. Final recommendations included: the development of a cancer registry to assist in surveillance and measurement of cancer incidence within the population; capacity building for increased timely diagnosis, professional development and physical infrastructure; awareness raising to reduce stigma and to facilitate an increase in health seeking behaviors throughout the population and research on low cost therapy and comparative assessment on treatment protocol. The recommendations are a positive step forward and reflect international concerns relating to increasing health seeking behaviour within the general population. Also acknowledged was the importance of understanding the psycho-social context in which childhood cancer and treatment is located. This is particularly important as issues such as stigma, have been shown to have a negative impact on health seeking behaviours, treatment accessibility and concordance (Dodor, 2009; Higgins 2009). Bangladesh does not have a childhood cancer registry to help inform planning decisions across the country. Clearly, there s a large unmet need in the community and the Bangladesh health system faces significant challenges in coping with the burden of childhood cancer (MOHFW, 2008). The increase in curative based treatment may be a relative slow process in Bangladesh with health priorities directed at communicable diseases such as diarrhoea, tuberculosis and malaria. Additionally, there is an increasing demand on health care resources from non-communicable diseases such as diabetes and heart diseases. (WHO 2010). Whilst having the goal of providing effective treatment for paediatric cancer within the general population is noble, preliminary work needs to be undertaken to aid the implementation of service delivery, professional training, standardised treatment protocols and health structures that support timely presentation and diagnosis. There are also opportunities for the development of community based supportive and palliative care services to reduce the burden and suffering of paediatric cancer (Khan, Ahmad, Anwar, 2008). Such services can be generally inexpensive to run, decrease the suffering and burden of disease and provide a strong platform for psycho-social support post death. Supportive and palliative care service implementation need not be exclusive to the furthering development of oncology services within Bangladesh and can provide a good compliment in professional training and capacity building, awareness raising and reducing stigma. Research conducted by McGrath (2009) shows that positive outcomes can be achieved by international collaboration. Recommendations from the international forum show that it is an effective method of galvanising opinion and focusing priorities. With international collaboration and research informing decision making it is hoped that this forum will be another step forward to decreasing the morbidity and mortality associated with paediatric cancer in Bangladesh and other resource limited countries. References - American Cancer Society (2007). Global cancer facts and figures 2007. - BBS. (2009) Statistical Pocket Book of Bangladesh 2008. Bangladesh Bureau of Statistics. Planning Division, Ministry of Planning, Government of the People's Republic of Bangladesh. - Cancer Help Guide. (2008) Child cancer causes thousands of deaths annually in Bangladesh. - Islam Saiful. (2009) Health, Economic and Childhood Cancer Profile in Bangladesh. Report of the department of Paediatric Surgery, Bangabandhu Sheik Mujib Medical University, Dhaka, Bangladesh. - McGrath, P, Holewa, H, Koilparampil, T, Koshy, C & George, S (2009) 'Learning from each other: cross-cultural insights on palliative care in Indian and Australian regions', International Journal of Palliative Nursing 15(10):499-509. - MOHFW. (2008) National Cancer Control Strategy and Pan of Action 2009-2015, Ministry of Health and Family Welfare, Bangladesh. - Khan, F., Ahmad, N., Anwari, M. (2008) Palliative Care in a Human Right, Journal of the Bangladesh Society of Anaesthesiologists. 21;2: 76 -79. - Raul C Ribeiro, (2008) Baseline status of paediatric oncology care in ten low-income or mid-income countries receiving My Child Matters support: a descriptive study. Vol 9. - Rice, S., McGrath, P. (2010) Successful Australia-India Cancer Research Program Expands to Bring Benefits to other Diagnostic Groups. Austral- Asian Journal of Cancer. 10;1. - UICC (2006). Childhood Cancer: Rising to the challenge: The International Union against Cancer (UICC) in the framework of the World Cancer Campaign. - World Health Organisation (2010), Country Health Profile. Accessed on http://www.whoban.orgcountry_health_profile.html 13 April 2010. - World Child Cancer facts. (2009) 6 Briset Street, London EC1M 5NR, United Kingdom


Profile: Dr. Clare O'Callaghan

D r. Clare O'Callaghan, a renowned expert in Music Therapy in Palliative Care and a unique researcher in this field is presently working as a Music Therapist at Peter MacCallum Cancer Centre, and Caritas Christi Hospice, St Vincent's Health, Melbourne, Australia. During 2008-09, however, Dr. O'Callaghan has taken two years leave while undergoing a Post Doctorate in Palliative Care, funded by the National Health and Medical Research Council of Australia. Initially trained as a social worker, Dr. O'Callaghan has focused on music therapy in cancer, neurology and palliative care since 1985, after completing an internship at The Memorial Sloan Kettering Cancer Center in New York. While Dr. O'Callaghan work background is mostly as a music therapist, she also has experience in education and research supervision. She has published 45 to 50 papers in music therapy, medical, arts, allied health and palliative care journals, textbooks, and conference proceedings, and has delivered over 30 conference presentations, including invited keynotes and lectures in USA, Canada, New Zealand, Ireland and Australia. This work has been recognized with honorary titles including Clinical Associate Professor, Department of Medicine, and Fellow, Faculty of Music, both held with The University of Melbourne. Dr. O'Callaghan main contributions have been to the development of music therapy methods, namely song writing and music supported counseling in palliative care, and research methodology, notably ways of representing patients' and carers' subjective accounts of their music therapy experiences. Dr. O'Callaghan current particular interest is the development of practice informed research initiatives, illustrating how the wisdom of experienced practitioners can be harnessed and extend knowledge. Notable contributions include demonstrating the utility of thematic analysis and grounded theory research methods, interpretive sub-group analysis, reflexive clinical journals, clinical data-mining (Epstein, 2001), and textual data management software. She is also a current Principal Investigator of a randomized controlled trial examining music as an anxiolytic in radiotherapy.

A Survey of Oral Cancer Using Fuzzy Linear Regression Algorithm

S Arulchinnappan, K Karunakaran, G Rajendran

  1. S Arulchinnappan
  2. K Karunakaran
  3. G Rajendran

Early detection of oral cancer is very important to reduce the mortality. Oral cancer occupies the top rank among cancers. An algorithm is used to analyze the demographic data set and identify the risk of oral cancer. This algorithm incorporates Fuzzy Linear Regression method to detect the risk of oral cancer. Using lower and upper bound values, the input variables are predicted and the regression line is drawn. An innovative Fuzzy Linear Equation is used in this algorithm to analyze the risk factors and to find the probability of oral cancer risks. It is found that smoking, chewing, drinks are the major risk factors that increase the chances of affecting this cancer. If all the above factors are high, the risk of affecting oral cancer is high. Result of this paper will help to improve the clinical practice guidance for analyzing the risk of oral cancer.


The Emerging Role of Predictive Assays In the Management of Head and Neck Cancer

Dr Loredana Marcu, E Yeoh

  1. Dr Loredana Marcu
    University of Oradea, Faculty of Science
  2. E Yeoh

Head and neck cancers, especially the advanced, unresectable ones, are difficult to manage due to their high hypoxic content and their ability to repopulate during treatment. Furthermore, the very large inter-patient variability of tumour response for the same treatment of this malignant disease necessitates a quantitative pre-treatment assessment of the tumour. Individualized treatment planning is therefore a tendency in oncology towards better management of disease. The aim of predictive assays is to enable an individual treatment protocol that is optimal for a particular patient to be chosen. Although a variety of predictive assays proposed have proved to be disappointing when trialed, a number of assays under investigation offer promise in predicting treatment outcome. The current paper presents a review of predictive assays for tumour response, in particular for head and neck carcinomas.

What Surgeons Must Know About Axilla Sentinel Lymph Node Biopsy In Early Breast Cancer

Dr Khaled Al Khaldhi, Ibrahim Alenezi, Philips Itty, Raafat Mady, Jean-Yves Bobin

MTHFR 677C T and 1298A C Gene Polymorphisms and Its Relation to Levels of Homocysteine, Folate Vitamin B12 and Vitamin B2 In Colorectal Cancer

Dr Lakshmi Krishnamoorthy, Sunil Chandy, Sadananda Adiga, G Ramesh, Girija Ramaswamy, M Vijayakumar, H.S Savithri

  1. Dr Lakshmi Krishnamoorthy
    Associate Professor, Department of Biochemistry, Kidwai Memorial Institute of Oncology
  2. Sunil Chandy
  3. Sadananda Adiga
  4. G Ramesh
  5. Girija Ramaswamy
  6. M Vijayakumar
  7. H.S Savithri

The enzyme 5, 10 methylenetetrahydrofolate reductase (MTHFR) plays a crucial role in folate and homocysteine metabolism. Folate is implicated in carcinogenesis due to its role in DNA methylation, repair and synthesis. In this casecontrol study, we have investigated the association of the MTHFR 677C T and 1298A C gene polymorphisms with plasma levels of folate, vitamin B12, riboflavin and homocysteine in colorectal cancer. Subjects were one hundred cases with histopathologically confirmed colorectal cancer and ninety three age and gender matched healthy controls. Folate and vitamin B12 levels were significantly lower among cases as compared to the control group. Riboflavin status did not differ between the two groups. Homocysteine levels showed an association with the MTHFR genotype. Markedly, elevated homocysteine levels were seen in individuals with the MTHFR 677TT, 1298AC and CC genotypes. An inverse association between vitamin B12 and homocysteine levels was observed in both cases and controls. In conclusion, these results suggest an inverse relation between vitamin B12 and plasma homocysteine levels. The interaction between the genetic polymorphism of MTHFR especially MTHFR 1298A C and increased homocysteine levels and the finding of a higher frequency of the CC genotype in the Indian population is important in terms of its potential impact on hyperhomocysteinemia.

Second Allogeneic Hematopoietic Stem Cell Transplantation for Relapse after Initial Allogeneic Transplant in Childhood Leukemia: A Single Center Experience

Dr Akira Kikuchi, Ryoji Hanada

  1. Dr Akira Kikuchi
    MD, PhD
    Division of Hematology/Oncology, Saitama Children?s Medical Center
  2. Ryoji Hanada

To evaluate the efficacy of second allogeneic hematopoietic stem cell transplantation (HSCT) for relapse after initial allogeneic transplant in childhood leukemia, we reviewed twenty-one patients who received second allogeneic HSCT for recurrent acute lymphoblastic leukemia (n=14), acute myelogenous leukemia (n=6) or chronic myelogenous leukemia (n=1). Of twenty-one patients, seven patients survived after the second HSCT with a median time of 16 months (range 2-95). Among several clinical characteristics, complete remission or chronic phase at the second HSCT showed a significant impact on better survival (46.9 +/- 18.7% versus 0%, p=0.0012). Although the outcome might be dismal especially in the patients who received second HSCT while in non-remission status, if remission of relapse is obtained after initial HSCT, a second HSCT should be considered as a curative treatment strategy for these patients.

Breast Cancer Genetics

Rodney J. Scott

  1. Rodney J. Scott

In the intervening period between now and the identification of major susceptibility genes for breast cancer considerable advances have been made in our understanding of not only the molecular mechanisms of disease but also how best to intervene to reduce the risk of overt disease. Understanding the role of genes associated with breast cancer will have important implications with respect to classifying patients who harbour an inherited predisposition to disease and sporadic cases that are a result of epigenetic or somatic changes into specific groups that will benefit from targeted therapies. Prophylactic options for women at increased genetic risk need to be studied such that maximum benefits from this knowledge can be applied to reduce the burden of disease.

Identifying Potential Improvements in Waste Handling within a Dialysis Unit: Implications for Health Care Waste Management in General

Ray James

  1. Ray James

Healthcare establishments by their very nature generate a significant amount of every conceivable classification and category of waste. In order for these wastes not to pose a threat to human health and the environment, they have to be properly identified, segregated and disposed of. Unfortunately, due to imperfect procedures, the wastes from the different groups get mixed together and end up being classed as hazardous waste or, conversely, not classified at all. This paper considers the type of waste generated in a haemodialysis unit, how it is handled and route of disposal. This information is used as a guide to how healthcare waste in general can be better managed and, through proper Health Care Waste Management, it can easily and cost-effectively address health care worker safety issues and avoid negative long-term health effects resulting from inappropriate disposal methods.

Transcriptional Pathways in Hypoxic Inflammation

Olga Safronova, Ikuo Morita

  1. Olga Safronova
  2. Ikuo Morita

Hypoxia is a micro-environmental factor frequently associated with tumors and inflammation. Hypoxia directs the development of inflammation via two central transcription factors HIF-1 and NF-kB. Transcription factors interact with histone modifying enzymes, like histone acetyltransferases (HATs) or histone deacetylases (HDACs), and recruit to their binding cites as a members of large multi-protein complexes. In the present review, we summarize the current knowledge of gene regulatory events occurring in chemokine network re-arrangement by inflammation complicated with hypoxia. In particular, we focus on the role of histone modifications and chromatin assembly of target promoters in defining gene-specific transcriptional responses in hypoxia.

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