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Temesgen’s Legacy
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Temesgen in Washington DC
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The Global Pattern of Childhood
Cancer and Advances made in
High Income countries
Aziza Shad MD
Lombardi Comprehensive Cancer Center
Georgetown University Hospital
Washington DC, USA
and
INCTR USA
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2020
 16-20 million new cancer cases each year
 ¾ of these in developing or resource-poor
countries
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Developed and Developing Countries
Some Facts
 Developing countries
 GNP per capita is 350$
 125 countries in the world
 Developed countries
 GNP per capita > 25000$
 10 countries in the world
 1/5 of the people in the highest income
countries have 86% of the GNP
 The bottom 1/5 have 1% of the GNP
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Estimates of Population
7000
6000
Millions
5000
4000
3000
2000
1000
0
2002
2005
Less Developed
2010
2015
2020
More Developed
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World Population Facts
 In 1990, developing countries accounted
for 78% of the world’s population and
86% of the world’s children below the age
of 15
 It is predicted that by 2030, 90% of the
world’s children will live in developing
countries
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The Global Childhood Cancer Burden
200000
150000
100000
50000
0
0-14 years
More Developed Countries
0-19 years
Less Developed Countries
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Patterns of Childhood Cancer
 40-50% of all pediatric cancer in the world is
leukemia or lymphoma
 treatment largely chemotherapy, but needs
expertise
 Pattern of cancer particularly different in SubSaharan Africa – high incidence of KS and BL
 KS largely HIV-related; preventable with HAART
 Brain tumors more common in more developed
countries – higher incidence than lymphomas
 May be partly due to failure to recognize
 Retinoblastoma also probably higher incidence but
lack of rural data misleading
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Frequencies (%)
USA-W
Brazil
Uganda
Zimbabwe
Leukemias
31
28
6
21
Lymphomas
10
21
9
3
7
2
4
7
21
13
2
8
9
0
6
4
29
1
1
6
4
1
3
41
11
11
4
9
15
2
4
18
CNS
Sympathetic
Retinoblastoma
Renal
Hepatic
Bone
Soft Tissue
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USA Whites 83-92 (0-14 yrs)
Leukemia
Lymphoma
CNS
Sympathetic NS
Retinoblastoma
Renal
Hepatic
4%
7%
3% 3%0%
2%
ALL 31%
NHL 10%
31%CNS 21%
7%
3%
Bone
Soft Tissue
9%
10%
Germ Cell
Carcinomas
21%
Other
14 per 100K
Data from IARC IICC 1998
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Uganda 92-95 (0-14 yrs)
Leukemia
4%
1%
Lymphoma
3%
6%
>66%
CNS
KS or BL
Sympathetic NS KS
Retinoblastoma
29%
Renal
Hepatic
Bone
41%
Soft Tissue
Germ Cell
Carcinomas
3% 1% 4%
Other
18 per 100K
1%
1%
6%
Data from IARC IICC 1998
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Pattern of Cancer in Ethiopia
 There are no reliable statistics on
the incidence of pediatric cancer in
Ethiopia
 With 42 million children under the
age of 18 years, there could be as
many as 5,628 new cases of pediatric
cancer each year in Ethiopia.
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Pattern of Cancer in Ethiopia





Leukemia
Lymphoma
Retinoblastoma
Wilms tumor
Bone and soft
tissue sarcomas
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Childhood Cancer Survival
 USA – approximately 12,400 children and
adolescents < 20 years are diagnosed with
cancer / yr
 7500 of these children are < 15 years of age
 Dramatic progress in treatment of cancer
in children in developed countries in the
last 25 years
 80% of children and adolescents diagnosed
before the age of 20 are cured
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Relative 5 yr Survival Rates
(SEER) All Sites, M and F
100
Percent
80
77.5
60
40
20
0
1975
1980
1985
Age 0-14
1990
Age 0-19
1994
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Five Year Survival Rates
(SEER) 1992-8, 0-14 years
Wilm'
Soft Tissue
NHL
Neuroblastoma
AML
ALL
Hodgkin's
CNS
Bone
0
20
40
60
80
100
Percent
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Childhood Cancer in Developing
Countries – The Reality
 Cure rate in developing countries
currently <30%
 Currently, only 20% of all children
with cancer receive treatment
sufficient to give them a chance for
cure
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Annual Deaths versus Cases
14 0 0 0 0
12 0 0 0 0
10 0 0 0 0
80000
D e a t hs
60000
C ases
40000
20000
0
M o re
D e v e lo pe d
Le s s
D e v e lo pe d
NB. Data extrapolated from existing registries –
the true situation is probably significantly worse
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The Problem: a Vicious Cycle
Limited
Resources
LOW
CAPACITY
Many Patients
With Advanced
Disease and
Many Potential
Patients
POOR
ACCESS
High
Mortality
Rate
Unmet
need for
terminal
care
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Access to Care
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infections
lack of education
and health
knowledge
poverty
Problems faced
by patients
anemia
lack of transport
and communication
lack of pediatric
cancer units
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Late Diagnoses
Courtesy, Dr Ashraf
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patients
Shortage of
antibiotics
Doctors
&
nurses
Problems faced
By medical
personnel
Poor
facilities
Shortage
Of cancer
drugs
Poor
training
Few specialized
units
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The Case to treat Pediatric
Cancer
 Many childhood cancers are highly
curable if detected early
 Treatment protocols have been
adapted for use in low income
countries that use readily available
and inexpensive generic drugs.

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The Solution: Build Capacity
Prevention
Less Limited
Resources
GREATER
CAPACITY
Education
Screening
Fewer Patients
with More Limited
Disease and
Fewer Potential
Patients
IMPROVED
ACCESS
Lower
Mortality
Rate
Less need
and greater
capacity for
terminal
care
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The International Network for
Cancer Treatment and Research
(INCTR)
 A not-for-profit, non-governmental
organization founded in 1998 by the UICC
and the Institut Pasteur in Brussels
 The National Cancer Institute, USA
assists the INCTR by providing financial,
technical and intellectual support
 INCTR assists developing countries
through a structured program of research
collaboration, education and training
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INCTR Mission Statement
INCTR is dedicated to helping build capacity for
cancer treatment and research in countries in which
such capacity is presently limited ……and to increase
the quantity and quality of cancer research throughout
the world.
Catalysis
Concerted Effort
Communication
Sustainability
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The Goals
 Cancer Cure
 Cancer Prevention
 Improvement in Quality of life
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The Mechanism
 Establishment of long term collaborative
projects which will have an immediate
impact on prevention or treatment
 Associate such projects with education
and training
 Use information collected in the course
of such projects as a foundation on
which to build future endeavors
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The Tool: Collaboration
Multiple networks: organizations, institutions, experts, supporters
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INCTR’s Network
Offices and Branches
Collaborating Units
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INCTR PEDIATRIC ONCOLOGY
PROGRAM
 Education and Training
 Clinical Research
 Palliative Care
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PEDIATRIC CANCER IS
OUR PRIORITY
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EDUCATIONAL ACTIVITIES
 Pediatric Oncology Training Programs
Educational Workshops
 Fellowship Program
 Visiting Experts Program
 Collaborative Efforts with other
Oncology Groups
 Development of Educational Material
 Telemedicine
 I-Path Program
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TRAINING AND EDUCATION
 Practical Management of Common
Pediatric Cancers
 Supportive Care Program
Guidelines for management of
complications of treatment, blood
transfusions, febrile neutropenia
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CLINICAL TRAINING AND
RESEARCH
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Projects: Childhood Cancer
RETINOBLASTOMA
Early detection and treatment
OSTEOSARCOMA
Treatment of metastatic disease
LEUKEMIA (ALL)
Treatment and molecular studies
BURKITT’S LYMPHOMA
Treatment and molecular studies
PALLIATIVE CARE
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MUMBAI
x
MUMBAI
o DELHI
DELHI
• CHENNAI
CHENNAI
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PALLIATIVE CARE
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IMPORTANCE OF PEDIATRIC
PALLIATIVE CARE
 60% of children will
die of their disease in
the setting of low and
middle income
countries
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PAX INITIATIVES
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

Nepal (Kathmandu and Bhaktapur)
India (Hyderabad)
Tanzania (Dar es Salaam)
Pakistan (early stages)
Brazil
Collaborative Efforts
 INCTR and MECC
 Educational initiatives
 3rd edition of Guidelines published
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GOALS FOR ETHIOPIA
 Train doctors to recognize and identify
early stage cancers
 Train a core group of pediatricians to treat
patients using cost effective protocols
designed for developing nations
 Help establish a sufficient supply of
essential chemotherapy drugs
 Increase capacity to offer palliative care
to patients with incurable disease
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GOALS FOR ETHIOPIA
 Twinning program with Georgetown
University and INCTR for training
and education
 Curriculum for Fellowship Program in
Pediatric Oncology and Palliative Care
 Telemedicine education
 Center of Excellence in Pediatric
Cancer
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Participation
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CURE FOR EVERY CHILD
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