Discussion
This study describes the status of pediatric cancer services in
Cameroon, and suggests the need for considerable expansion in reach,
type, and specialization of services provided. Nearly two-thirds of
current staff in pediatric oncology services have not received prior
pediatric oncology capacity building. Pediatric chemotherapy
pre-treatment investigations are expensive for the average Cameroonian
family. As a result, about 30% of children with cancer abandoned
treatment. In addition, the overburdened oncologists were required to
conduct patient education and disclosure of cancer status, sometimes in
combination with caregivers or parents. Regarding data management, data
collection tools were available but not harmonized at cancer sites, and
there was no systematic data reporting scheme for pediatric cancer data.
The fact that just two of the nearly 6,000 facilities in Cameroon are
offering pediatric oncology services, is an appalling finding, which
further re-iterates the negligence that these categories of patients
with curable cancers face. To us, this is clarion call to action to
address this unmet need for pediatric cancer patients- both to the
government and the international donor committee.
These findings suggest that pediatric cancer services in Cameroon need
serious and urgent expansion and modernization, which lends support to
findings from most parts of Africa. Only about 71% of countries in
Africa had a functional national cancer control programme, with
substantial variations in cancer services within countries [13].
Therefore, the need to address these service capacity gaps is imminent
as these will enable investments in cancer control to prevent premature
death. This can be done in a phased approach, progressively expanding
pediatric chemotherapy services to targeted regional hospitals and
similar structures across the nation, creating and integrating regional
cancer control units under the leadership of regional delegations of
public health. At the health district level, community health workers
need to be trained to identify early warning signs and rapidly detect
suspected cases through simple gestures.
Adequate human resource capacity is critical for effective and holistic
cancer management. However, surveyed cancer treatment centers lacked the
human capacity for optimal pediatric cancer care. Furthermore, the
University system does not produce sufficient oncologists to match the
escalating burden of this disease. Nearly two-thirds of staff involved
in pediatric oncology service had not undertaken specialty training in
this domain, suggesting the need to design and roll out several human
resource interventions for cancer control in the country. This may
involve instituting a system for periodically training key staff,
including pediatric oncologists, pediatric oncology surgeons, and
oncology nurses. Another entails strengthening the capacity of existing
staff by rolling out training on the early detection of common cancers
and building their capacity on essential concepts of chemotherapy and
palliative care. Improving the quality of health personnel in pediatric
treatment facilities can play a great role in children’s treatment
outcomes [14]. This should include incorporating palliative into all
childhood cancer treatment facilities to meet the multidisciplinary
needs of children and their families as well as proven approaches to
disclose information to patients and their families The latter is
important because poor management of information of the disclosure
process can result into complications, grief, and poor mental health in
children and their surviving families [15]. It is also important to
implement systems to provide newly recruited staff with skills to
support cancer care and treatment effectively and rapidly. Furthermore,
there is a need for continuous human resource gaps assessments and
addressing training and retraining needs.
In this assessment, Burkitt lymphoma was reported as the most treated
pediatric cancer, representing nearly one-quarter of all pediatric
cancer patients in Cameroon. This highly aggressive and fast-growing
tumour has been previously described as the most common childhood
cancer, especially in tropical African countries where malaria is
holoendemic [16]. Recent evidence suggests a strong association
between malaria and Burkitt lymphoma [16, 17]. However, whether this
association is causal remains uncertain, partly because data on the
epidemiology of Burkitt lymphoma in sub-Saharan Africa are rare even
from the most affected countries like Malawi, Uganda, Nigeria, and
Cameroon. In addition, over 80% of Burkitt lymphoma is associated with
the Epstein-Barr virus, and Burkitt lymphoma is predominant in boys and
children aged 5-9 years.
We found a high abandonment rate for pediatric cancer treatment of about
30%. Specifically, about 12% of children who needed chemotherapy did
not get it, and approximately 20% of those on chemotherapy did not
complete the required treatment sessions. High treatment abandonment
rates have been reported in sub-Saharan African countries ranging from
15-60%. The reasons for treatment abandonment are multifactorial,
including a high cost of care, poor awareness, long distances to
treatment centers, absence of health insurance coverage, the high
toxicity of treatment, long chemotherapy sessions, absence of social
support, and fear of the unknown [18–20]. Inequities in treatment
options are a major factor in the disparity in treatment between
developed and developing, yet this is under-researched and receives
little attention when reporting the Sustainable Development Goals
[21]. In addition, treatment abandonment rates are associated with
failure and poor survival rates [19]. Therefore, there is a need to
improve access to chemotherapy by harmonizing protocols, upgrading the
technical platforms of specialised structures, ameliorating forecasts,
and strengthening financial resource mobilization for procuring cancer
products.
Cancer status was mostly disclosed by already overburdened oncologists
and oncology nurses in most instances, despite the availability of staff
who could handle patients’ status disclosure if empowered with the
appropriate training. Organizing capacity-building sessions on status
disclosure for relevant hospital staff and community health workers
could go a long way to improve pediatric cancer patient education,
tracking and follow-up.
Data collection and reporting are critical for informed decision-making
for enhanced health services. Although both surveyed facilities had data
collection tools, data collection was not harmonized in terms of tools
for collection and time for collection. In addition, there was no scheme
in place for reporting pediatric cancer data to regional and central
levels for policymaking. This significantly hinders research and
development, warranting developing a harmonized national data collection
tool with selected variables and indicators. In addition, the said
indicators could be customized into the national health information
software 2 (DHIS2). Furthermore, the data tools could be leveraged in
the long term to build a functional pediatric cancer registry.