Pioneer in Global Childhood Cancer Care Saluted

Janis C. Kelly

April 15, 2011

April 15, 2011 — Although he has inspired major changes in childhood cancer care in developing countries over the past decade, Raul Ribeiro, MD, from St. Jude Children's Research Hospital in Memphis, Tennessee, was a "late convert" to pediatric oncology.

Dr. Raul Ribeiro

After completing his training in pediatrics in Brazil, Dr. Ribeiro wanted to continue in pediatric neurology, but no fellowships were available.

That dead end turned out to be fortuitous, and led to Dr. Ribeiro onto a career path that includes his being awarded the Paul P. Carbone Award in International Oncology from the International Network for Cancer Treatment and Research (INCTR).

The award recognizes outstanding contributions to oncology or cancer research in one or more developing countries by an individual from a resource-rich country.

INCTR is a nonprofit organization established to help control cancer in developing countries through the development of infrastructure for cancer treatment and research. Dr. Ribeiro accepted the award this week at INCTR's biennial meeting in Brussels, Belgium.

But that is getting ahead of the story.

Back in Brazil, Dr. Ribeiro's department head recommended that he pursue pediatric oncology and referred him to Brazilian physician John (Rhomes João Amin) Aur, MD, who was one of the pioneers in treating leukemia at St. Jude's, the first and only National Cancer Institute–designated Comprehensive Cancer Center devoted solely to children.

Dr. Ribeiro told Medscape Medical News that "because the leukemia patients in my institution did so poorly in 1978 — every one of them died — I looked into it. Dr. Aur wrote back to say that with modern treatment it was true that leukemia in children could be cured. I eventually visited with him and decided that there was incredible potential at St. Jude's."

"When I came here for my fellowship in 1984, about 60% to 70% of pediatric patients with acute lymphoblastic leukemia were cured. Today, more than 90% are cured," he said. Dr. Ribeiro attributes this to the integration of multidisciplinary approaches, the increasing intensity of chemotherapy, and improvements in supportive care.

However, these advances heightened Dr. Ribeiro's concern about the disparity between pediatric cancer outcomes in hospitals like St. Jude's and those in resource-poor countries.

And that concern led to the work for which he was honored by the INCTR.

Savvy and Commitment

"Half of my time is dedicated to developing the capacity to treat pediatric cancer in countries with limited resources. In the United States, 80% of kids are cured. In the developing world, 80% of kids with cancer are not even treated, and survival is less than 10%," said Dr. Ribeiro.

In 1996, St. Jude's started a "twinning" program to partner with institutions and help them develop strategies to gain access to treatment for pediatric cancer. The very successful model involves going to a community, establishing a relationship with a pediatric oncologist and a grassroots foundation, and starting from the bottom up.

"If you try to go through the government first, they will often say that cancer cannot be cured or that cancer does not happen in kids, so they will not devote resources to pediatric oncology. So first we demonstrate success, then we establish an alliance with the government to develop national programs," Dr. Ribeiro explained. The St. Jude's program now includes projects in Honduras, El Salvador, Guatemala, Costa Rica, Brazil, Ecuador, Venezuela, Mexico, the Philippines, Jordan, Lebanon, and China.

Dr. Ribeiro is director of the hospital's International Outreach Program and has helped establish partnerships with 19 medical institutions in 14 countries. To support these projects, St. Jude's devotes 1% of its total institutional budget to humanitarian programs.

"If more institutions in the developed world would give 1% of their budgets to help other nations develop health-associated projects, I think the world would be much, much better. It would not take more than 1%," Dr. Ribeiro said.

Let's Meet Online

In 2002, Dr. Ribeiro led the development of Cure4Kids, a free online educational Web site designed to educate health professionals worldwide about catastrophic childhood illnesses. The site promotes collaborative work spaces; training for better management of patient information; and online consultation and discussions of critical issues related to pediatric oncology and hematology. Today, the effort has thousands of registered users in more than 175 countries.

"In the beginning, efforts by American oncologists to help in developing countries were not well organized because we didn't have the technology we now have," Dr. Ribeiro said. "Today I can discuss the patients at the developing country partner sites in real time using inexpensive Web conferencing tools. Every day I can meet with them, discuss cases, make recommendations, and keep close contacts. Today, with social network tools, we have the means to be really effective. Learning occurs at the point of contact."

Federico Guillermo Antillon-Klussmann, MD, Phd, from the Unidad Nacional de Oncología Pediátrica, Guatemala City, told Medscape Medical News how the program works in Guatemala. He was a fellow at St. Jude Children's Research Hospital in 1995 and returned to Guatemala in 1997 to establish a pediatric cancer program.

"Dr. Ribeiro and the International Outreach Program at St. Jude's were key to establishing a collaboration agreement and a pediatric cancer program in Guatemala. We began programs that include treatment for acute lymphoblastic leukemia, acute myelogenous leukemia, Burkitt's lymphoma, and acute promyelocytic leukemia in Central America. There are weekly case discussions on patients on protocol. (Each protocol has a separate day of the week). Dr. Ribeiro has been a mentor and an example to follow for developing pediatric oncology.

In Southeast Asia, pediatric oncologist Mae Concepcion J. Dolendo, MD, medical director of the Davao Partner Site in the Philippines, said: "I am very happy about the INCTR award for Dr. Ribeiro. I could not think of any other person more deserving of the award."

Dr. Dolendo is working with Dr. Ribeiro as part of the St. Jude twinning model, and also on the Mindanao Pediatric Cancer Care Network through World Child Cancer, which Dr. Ribeiro helped found.

"This set-up utilizes the concept of a local twinning, in which satellite clinics in key areas of Mindanao, Philippines, are established to widen our reach to more children with cancer," Dr. Dolendo said. "Dr. Ribeiro is central and instrumental in bringing the twinning program to Southeast Asia. This is a significant step because the majority of the children in the world are in Asia, and teaching doctors and healthcare workers to properly treat these children improves survival and cure for many, many children"

"Dr. Ribeiro personally participates in our Web conferences and has given us wise and practical advice, which we were able to use productively for our patients. He has also provided us a lot of moral support and encouragement as a mentor. His passion and dedication to his work and to improving the plight of children with cancer around the world, no matter where they are, is a constant source of inspiration for us," she continued.

The effectiveness of these projects is also notable in Honduras. Ligia Fu, MD, from the pediatric oncology service at Hospital Escuela in Tegucigalpa, told Medscape Medical News that "since we started our participation as partner sites with St. Jude's [International Outreach Program], we have made a lot of changes in the care of our children with cancer. We can proudly we say that our survival rate has improved dramatically, from less than 30% to 70%."

Dr. Fu added that "Dr. Ribeiro participates with us every week through online meetings, and we are able to consult him about clinical cases or diagnostic difficulties we have with our patients. With his wise advice, we have been able to make important decisions for our patients' treatments and care. . . . I think that Dr. Ribeiro deserves this award because of his dedication and mission to improving the childhood cancer survival rate in developing countries."

Dr. Ribeiro enthusiastically encourages young doctors to consider pediatric oncology as a specialty. "Pediatric oncology is the most exciting field in medicine," he said. "It incorporates all of pediatrics. Pediatric oncologists tend to want to change the world and nature. Cancer is a complex developmental disease, and the field attracts doctors who have a need to change things and are not easily discouraged."

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