'Twinning' Strategy Improves Cancer Care in Developing Nations

Roxanne Nelson

December 23, 2011

December 23, 2011 (San Diego, California) — A new strategy may be able to provide expert care to patients with cancer in low-resource nations, even if local specialists are not available. In a team approach that "twinned" physicians in Rwanda with pediatric oncologists in Boston, Massachusetts, 5 of 10 pediatric patients with lymphoma received curative therapy at a rural Rwandan hospital.

The results of this project were presented here at the American Society of Hematology (ASH) 53rd Annual Meeting.

"We now have 3 more lymphoma patients who are in the middle of therapy and who are doing well so far," said study author Leslie Lehmann, MD, who is clinical director of the pediatric stem cell transplant program at Dana-Farber/Children's Hospital Cancer Center in Boston. "And we are continuing to get more patients in the program."

The program also takes care of children with other types of cancer, but the ASH presentation was limited to lymphoma-leukemia because of the hematological focus of the meeting. "We have kids with a variety of other cancers, including Wilms' tumor and rhabdomyosarcomas," Dr. Lehmann said in an interview. "A total of 26 patients have been treated."

The patients receiving treatment in this program came to the hospital seeking medical care, so they are self-referred in that sense, she explained. "And then we treat children with a limited number of illnesses — the ones which we have available drugs for. There are still drug procurement issues, and that is one of the problems going forward."

The drugs that are used are all available generically, which significantly lowers their cost. There are also adult patients who are being treated with the same model, including some with chronic myelogenous leukemia, and Novartis is providing imatinib (Gleevec) through one of their programs that helps patients in the developing world, Dr. Lehmann said.

Growing Cancer Concern

Nations in the developing world have traditionally devoted their limited public health resources to epidemic infectious diseases, but noncommunicable conditions such as cancer and cardiovascular disease are rapidly become a concern. As previously reported by Medscape Medical News, cancer has become a leading cause of death and disability in low- and middle-income countries, and almost two thirds of the 7.6 million cancer-related deaths occur in developing nations.

However, even though these nations account for almost 80% of disability-adjusted life-years lost to cancer, only about 5% of global cancer resources are spent in this part of the world. "The situation has become more complex," said Julio Frenk, MD, PhD, former Minister of Health of Mexico and current dean of the Harvard School of Public Health in Boston, in an interview last year. "Cancer was the priority of wealthy nations, infectious disease the problem of poor nations. It used to be more black and white."

In industrialized nations, 80% of pediatric cases of lymphoma can be cured. However, this rate of success is dependent on definitive diagnosis, expert administration of chemotherapy, and experienced follow-up care, which is often impossible to accomplish in resource-poor areas. One major problem in delivering care is an inadequate number of existing pediatricians subspecializing in oncology. In Rwanda, for example, a nation of more than 11 million people, there are no trained pediatric oncologists, explained Dr. Lehmann.

"The ultimate goal is to train physicians, but at this point, there isn't subspecialty training in Rwanda," she said. "And it is a long process. For example, the doctors we are working with in Rwanda haven't even trained in pediatrics yet. So they would have to do a pediatric residency first, and then one in hematology/oncology."

First of its Kind

The twinning model, a first-of-its-kind strategy, was set up 5 years ago in Rwanda, at the Rwinkwavu government hospital. The facility is supported by Partners in Health, a nonprofit healthcare organization based in Boston that works with national ministries of health to operate health centers and hospitals in impoverished areas of the world.

Each case was managed by a team that included a Rwandan physician without specialty training; a Rwandan nurse coordinator; a Rwanda-based, US-trained pediatrician; and a US-based pediatric oncologist. All biopsies and radiologic staging studies were obtained in Rwanda, but the pathologic diagnoses were made at Brigham and Women's Hospital in Boston.

"So whenever we are treating someone, we know that it is based on a pathologic diagnosis that was made in the US," explained Dr. Lehman. "This way we are assured of the correct diagnosis, before we given chemotherapy."

Each child had a treatment plan that was developed with the consulting pediatric oncologist, and chemotherapy was prescribed by one of the US-trained pediatricians and administered by Rwandan nurses under the supervision of the local general physician. Broad-spectrum antibiotics were available, but blood cultures could not be performed. Patients who needed radiation therapy were transported to neighboring Uganda for the treatments.

Of the 10 patients with lymphoma treated thus far (age, 3 - 15 years; median age, 9.5 years), 5 have completed therapy. Two had Hodgkin's disease, 2 had HIV-associated large cell lymphoma, and 1 had Burkitt's lymphoma. Chemotherapy was either cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP; n = 3) or adriamycin, bleomycin, vincristine, and dacarbazine (ABVD; n = 1). One of the patients with stage 1 lymphocyte predominant Hodgkin's disease is currently being observed without adjuvant therapy after complete surgical excision.

All 5 children show no evidence of disease recurrence at a median of 14 months (range, 4 months - 4 years) after completion of their therapy. As for the remaining 5 children in the cohort, 2 patients are currently receiving therapy (recurrent Hodgkin's disease, HIV large cell lymphoma) and are in remission. Two of the patients died of treatment complications, and 1 patient died of progressive disease while receiving chemotherapy.

"These data suggest that chemotherapy can be administered with curative intent to a subset of these patients in the setting of a confirmed pathological diagnosis," note the authors. "This approach provides a platform for models of care that rely on local physicians acting in concert with trained consultants from the developed countries to deliver subspecialty care in resource poor settings."

The study was funded by Partners in Health. The authors have disclosed no relevant financial relationships.

American Society of Hematology (ASH) 53rd Annual Meeting: Abstract 4222. Presented December 12, 2011.

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