4. Discussion
Southeast Asia is home to approximately 168 million children aged below 14 years, constituting one-fourth of its total population. At an estimated incidence of 92 cases per million, the region sees an estimated 16 000 new cases of childhood cancer per annum – a disproportionate 9.6% of the global pediatric cancer burden29. Childhood cancer care and control programs in the region are still lacking, however substantial progress has been made in recent years, particularly via development of cooperative group structures 29. We found that most countries in Southeast Asia have developed childhood cancer referral centers (Fig 1A), the majority of which are staffed by at least a dedicated pediatric-trained oncologist (Fig 1B). This is a tangible result of directed efforts in the field of pediatric oncology in Southeast Asia involving bodies and initiatives such as SIOP, St Jude Global, WHO Global Initiative for Childhood Cancer, VIVA Foundation for Children with Cancer, Southeast Asia Pediatric Hematology Oncology (SEAPHO), and Asian Children’s Care League 29. Such initiatives have included establishment of national pediatric cancer programs, education and training of the pediatric cancer healthcare workforce, and development of adapted-therapy treatment protocols. This demonstrates the impact of international partnerships in advocating for increased attention toward childhood cancer care as a global health priority30.
Pediatric solid tumor care is typically centered in referral centers and depends on the level of individual subspecialty capabilities and their coordination within multidisciplinary teams 17. Presenting symptoms of pediatric solid tumors are more easily recognized than leukemias and brain tumors 31-33, however their diversity of histological types and anatomical locations pose additional challenges to their successful management. Pediatric oncologists, the usual leaders of multidisciplinary solid tumor teams, need to collaborate with surgeons, radiologists, pathologists, radiation oncologists, nuclear medicine physicians and nurses. In this survey, we found only 4 of 46 PSTUs had pediatric-trained expertise in all 6 key subspecialities, with the rest supported mostly by general specialists. Despite this, 24 PSTUs could still organize regular MDTBs.
Pediatric surgeons were available in 91% of the PSTUs studied, the next most prevalent group of specialists after pediatric oncologists. Surgeons play an important role particularly in aspects of local control as well as venous access for chemotherapy. Interestingly, our survey found that the oncology-dedicated workload among pediatric surgeons was much lower than pediatric oncologists (22.7% vs. 90.5%). Correspondingly, most were general pediatric surgeons without oncology-specific training. This reflects a very small numbers of centers in the region capable of providing level 3 surgical expertise with dedicated pediatric oncology surgeons 17. Notably, expert groups have identified that pediatric surgery is a less recognized priority in global health, with less-established efforts to date that have focused on development of the speciality in LMICs34-36. Radiologists and pathologists play a significant role in diagnostic planning and recommendations. Only half of PSTUs were staffed with pediatric-trained radiologists and pathologists. The availability of these specialists in PSTUs was significantly associated with increased incidence of pediatric MDTBs. Correspondingly, the most acute gaps in multidisciplinary solid tumor care in this region were identified to be in the areas of radiographic and pathological diagnostic support (Fig 3D). The numbers of radiation oncologists and nuclear medicine physicians were even lower, particularly when considering pediatric-trained numbers. This highlights the manpower challenges faced by PSTUs, in addition to issues of availability of essential chemotherapy, surgery and basic diagnostic modalities.
Effective MDTBs require members’ commitment to meet regularly as part of their recognized clinical duties, prepare and present required information and openly deliberate treatment recommendations in an evidence-based manner 23. In limited resources settings especially in LMICs, organizing MDTBs can be an organizational burden and amounts to extra workload for the involved personnel23,24. Half of respondents reported that “lack of time” and “too much workload to attend the meeting regularly” were among the main barriers they faced personally. Notably, we observed that most MDTBs shared common views on ideal goals and factors for success, and that oncologist and surgeons’ opinions did not differ significantly, particularly on workflow-related matters such as prioritization of cases for discussion and tangible benefits for PSTU teams. Most MDTBs had necessary infrastructure such as meeting venues and access to radiology images before and during the meeting. Interestingly, organizational challenges appeared to be a common problem. Despite most respondents ranking the need for clear guidelines and pre-meeting agendas highly, only about 70% of respondents reported having a designated coordinator and circulation of pre-meeting agendas and patient lists. This points to an underlying lack of support systems among pediatric cancer units in Southeast Asia – a gap which likely also accounts for the observed lack of registry data from centers in this region 31,33,37.
Delivery of care for pediatric oncology patients is also impacted by social, economic and cultural factors. While the formation of an MDTB is a first essential step for PSTUs to ensure correct diagnoses and proper treatment recommendations, obstacles to childhood cancer care faced by LMICs extend beyond this. Globally, there are significant gaps in the distribution of financial resources for pediatric cancer care: expenditure in LMICs amount to only 6.2% of global spending, yet they care for a disproportionate two-thirds of childhood cancer cases worldwide 29. While over the previous decade, Southeast Asian countries received significantly less funding from international grants (31), such support has increased in recent years (32). Yet, our data demonstrates how imbalanced resource distribution in Southeast Asia impacts childhood cancer care in highly populous and lower income countries. Southeast Asian LMICs with higher GNI per capita had more pediatric solid tumor MDTBs, particularly Malaysia and Thailand, with the 2 highest GNIs per capita (Fig 1). However MDTB frequency did not correspond with the size of national pediatric populations: Indonesia, Philippines and Myanmar have 70% of the children under 14 years in Southeast Asia but only 40% of the MDTBs. All 3 countries have a GNIs per capita below US$4000. Additionally, the diversity of ethnicity, language, religion and culture in Southeast Asia add to the challenge of health equity. Also, availability of essential medicines, abandonment and local socio-cultural nuances such as use of traditional medicines are yet more challenges, all of which are under-studied in the Southeast Asian region 38,39.
This study was limited by the scope of coverage of PSTUs in the Southeast Asian countries, with some being inadvertently missed, and some not responding to the survey. Nevertheless, the 80.4% of PSTUs profiled represent at least each of the main national referral centers in the region, most fulfilling criteria as Level 2 Pediatric Cancer Units (PCUs), according to the SIOP PODC framework 17. It can be reasonably expected that centers not covered by this study would be PSTUs with Level 1 facilities especially from lower GNI countries such as Cambodia, Laos and Timor Leste, and more populous or geographically larger countries such as Indonesia, Philippines and Vietnam. This study may also over-represent the pediatric solid tumor capabilities of the region. Because of the heterogeneity of training models in various countries, no specific definitions were imposed to differentiate between “pediatric-trained” or “general” specialists, and this was left to individual respondents’ interpretation. In cases of discrepant responses between oncologists and surgeons, the higher level of expertise was taken to represent the center, given the liberal definition applied. Even then, most PSTUs lacked pediatric-trained pathologists and radiologists, as well as radiation oncologists and nuclear medicine physicians. These numbers would be expected to be even lower in level 1 PCUs which were not covered in this study. Notably, other surgical subspecialties involved such as ophthalmologists and orthopedic surgeons were also not profiled in this survey.
From this study, we propose several recommendations to develop PSTUs and MDTBs to improve pediatric solid tumor care in Southeast Asia:
  1. Development of multidisciplinary teams. LMIC PSTU teams may benefit from intentional exposure and modelling from established PTSUs. Adapted systematic recommendations could be proposed to guide team development and constitution, and MDTB execution, including best practices for pre-meeting preparation, documentation of proceedings and self-auditing40,41.
  2. Optimization of local MDTB administration. PSTUs may benefit from improved organization of MDTB meetings. Increased involvement of non-clinical staff or nurses may help to overcome workload and time limitations faced by clinicians. Recognizing MDTBs as a professional activity with incentives for attendance such as CPD points may further increase participation.
  3. Expansion and ongoing support for regional training resources. Pediatric oncology training programs and collaborations in Southeast Asia that have come about as a result of recent non-governmental organizations’ support should be continued and widened now to include and develop more specialties, especially pediatric surgery, radiology and pathology, with enhanced support from governmental bodies and international charities.