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:
- 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.
- 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.
- 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.