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Comprehensive Care in
Pediatric Cancer Patients
Dr. Salah S. Abdel Hadi
Professor, Pediatric Oncology
NCI, Egypt
Introduction
Cancer in children & adolescents is rare.
 Children & adolescents with cancer should
be referred to tertiary care centers where
multi-disciplinary care is available.
 Treatment, supportive care &
rehabilitation are offered to achieve:
a) optimal survival.
b) quality of life
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Introduction
Pediatric cancer management is one of
the success stories of modern medicine.
 The success of medical treatment of
childhood cancer has significant public
health impact when considered in terms of
person years of potential life saved.
 There is a life time saved for every child
cured of cancer.
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Introduction
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Cancer in children is a significant problem of
mortality in developed countries.
Cancer is second cause of childhood death in
US among 1 to 14 year olds (following accidents
and preceding congenital anomalies and
homicide).
In developing countries, cancer trails infections
as a cause of mortality; but continues to rise
within list of priorities as infections become
controlled.
Introduction
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Malignancies in childhood occur with an
incidence of 13-14 per 100,000 children.
Of the world’s population of 6 billion,
650 million reside in developed countries with
older populations/smaller fraction of children.
The number of new cases annually exceeds
200,000 world wide.
The proportion of new cases in developing
countries currently at about 85% and rising.
Introduction
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The population of developing countries
represented 78% of the global total in 1990.
Countries with limited resources accounted
for 86% of the world’s children in 1990.
“Projected to increase to more than 90% by
2030”.
The major killers of children in countries with
limited resources remain:
a) infections
b)malnutrition
c)diarrhea/dehydration.
Introduction
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However there is an increase in the relative
importance of cancer in the spectrum of disease
in childhood in some developing countries.
In China, cancer is now the most common cause
of disease related death in school aged children.
With future improvements in standard of living,
success of immunization programs and
disseminating medical services, childhood
cancer will emerge as a major cause of death in
children in developing countries
Priority of Oncology Problem
In Egypt
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Pediatric oncology on the rise.
Control of acute illnesses in pediatrics.
 Success of vaccination program.
 Population increase (1.8million births/year).
 Better diagnostic facilities & know how.
 Improving patient survival.
 Increasing specialized care centers.
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Outlets for Pediatric Oncology
Service In Egypt
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Universities (14 governmental & private)
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Cancer institutes
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National cancer institute, Cairo University
South Egypt Cancer Institute, Assiut University
Ministry of Health
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Departments of pediatrics: liquid malignancies
Departments of radiation oncology: solid tumors
Nasser Institute
Cancer Centers
Armed Forces and Police hospitals
Private Sector
Background
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Chemotherapy was introduced to treat childhood
leukemia in 1940s.
Prognosis of childhood cancer dramatically
improved over the years.
5 year survival (diseases uniformly fatal in
chemotherapy era) = 75% for all childhood
cancer diagnosed between 1989 and 1995.
Multi modality approach becomes standard in
managing most childhood cancers.
Principles
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Pharmacologic interventions in most cases “antihypertensives” administered with intent of
controlling disease/symptoms rather than cure.
Exception lies in anti microbial and anti cancer
chemotherapy.
The model for curing cancer is based on
successful model of curing bacterial infections.
Principles (cont.)
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The strategy exploits differences between
cancer and normal cells attempting to eradicate
or kill cancer cells.
Anti-cancer drug discovery relied on screening
to evaluate anti-proliferative or cancer cell killing
effects of drugs on tumor cell lines invitro.
This method identified drugs that are cytotoxic
and non selective. Most conventional anticancer drugs produce substantial clinical toxicity.
Management
Protocol treatment
 Tumor boards
 Referral attitudes (tertiary care center)
 Team approach
 First chance is best chance and only
chance of cure.
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Protocol Approach
Patients treated on protocol do better than
individually managed.
 Thesis approach vs. protocol approach
 The Indian experience
 Controversies of unifying protocols
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Upgrading of participating centers
 Development of two protocols
 Referral of patients during intensive
management.
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Team Approach
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Shift from: - unipolar (doctor, leader &
remaining followers) to
- multipolar (teams of
specialized professionals
working in harmony)
Development of trained professionals in:
a) data management
b) infection control,
c) terminal care
Infection Control
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Education
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fever/neutropenia
- vaccinations
Nosocomial infections
infection control committees
 micro biological surveys
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Hepatitis
national level
 hepato toxic agents
 management slip ups
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Compliance
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Education:
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- society
- medical milieu.
Team approach
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child
family
doctor
nurse
social worker
- clinical pharmacist
- dietitian
- play therapist
Proper/practical dealing of
- fears
- mis-concepts.
Late Sequelae
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Proper choice of chemotherapy:
Agents
 protocols
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Avoidance of management by combined
chemo/radiotherapy.
 Avoidance of radiation therapy in early
childhood “deferred rth. in brain tumors”
 Avoidance of mutilative surgery
 Early and aggressive rehabilitation
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Information Deficits
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Development of national registry
Development of institutional data basis
Development of:
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data management facilities
data managers
research nurses.
Development of multi center studies.
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Prospective
Randomized
Double blind
Integration in Society
Education/rehabilitation
 Psychosocial adaptation
 Job/career opportunities
 Late effects committees in collaboration
with medical oncology
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