DiscussionÂ
Assessment of accurate incidence and prevalence of pediatric cancer is
limited by the absence of a central registry since low and middle income
countries like Pakistan lack the resources and organization needed to
establish effective population based cancer registries; these can also
serve as public health surveillance tools to plan, monitor and measure
cancer related services, research and education5.
However, hospital based cancer registries can provide information about
common cancers, localization, age groups, and treatment options
available for patients as well as their response rates and survival
outcomes to establish the exact need for cancer care services and health
policy planning in that particular region6. For a
reliable hospital based registry, coordination between the local
oncologists and trained cancer registrars is required to find, abstract
and register cases in an organized database. Collaborations with other
centers catering to pediatric cancer patients in Pakistan to combine
validated databases can facilitate improvements in survival outcomes and
cancer care in that region and eventually lead to the formation of a
proper population based registry.
Aga Khan University Hospital is one of the largest tertiary care
hospitals in the country and has been maintaining a pediatric cancer
registry since 2009. It is one of the primary referral centers for
quality pediatric cancer care, making the registry data capable of
commenting on commonly seen cancers in the population. For the time
period 2010 to 2019, there was an increasing trend in the cases of
pediatric cancers presenting each year with numbers almost doubling over
the ten year period- this implies an increase in pediatric cancer
incidence and could also be attributed to increased awareness and
accessibility to healthcare services leading to prompt diagnosis and
treatment initiation. A higher proportion of male patients (62%) was
observed in our hospital and this is commonly seen globally such as in
the 18 registries included in SEER (Surveillance, Epidemiology and End
Results) as well as 162 out of 183 national registries evaluated
Globocan 2018- this could be attributed to hormonal variations
particularly for bone tumors although a combination of immune related,
genetic and social factors could play a role7; 8. In
the time period studied, leukemias(33%) were most commonly seen,
followed by CNS tumors (17.8%) and lymphomas(11%); this proportion
corresponds to Globocan’s estimates for the most common childhood
cancers- leukemia and CNS tumors accounted for 45% of cases and 57%
deaths according to the 2018 report7. Patterns of
site-wise case distribution are also somewhat similar within Pakistan-
data from a study reporting pediatric cancer cases from 3 centers within
Pakistan between 2016 and 2018 also showed a male predominance and
leukemia, lymphomas and retinoblastomas as the top three
cancers9. The Punjab Cancer Registry, which collects
cancer incidence from 27 collaborating centers within Punjab province
reported acute lymphoblastic leukemia, glioma and Hodgkins lymphoma as
the most commonly occurring childhood cancers in
202010. Globocan also reported most of the cases(42%)
in the under-5 age group followed by the 5-9 age group- however, we had
more patients (27%) between the ages of 15 and 19, followed by the
under 5 age patients (23% cases).
Pediatric cancers mostly present with non specific signs and symptoms
that can be easily attributed to more common, benign conditions, thus
diagnosis and workup is often delayed, especially in resource limited
settings like Pakistan where the sophisticated technology required to
make accurate diagnoses is not available at most healthcare facilities
coupled with a general lack of health awareness, cultural factors and
financial constraints11. This is particularly
concerning since Globocan ranked South-central Asia and Eastern Asia the
highest for incidence of cancers in children (<19 years), with
an incidence of over 143000 according to the 2020 estimates. Over the
past few decades, overall survival of childhood cancer patients has
improved from less than 30% to about 80% in high income
countries12. However this number is much lower in
Pakistan and other low and middle income countries. This burden is
complex due to the number of intrinsic hurdles negatively affecting
outcomes such as malnutrition, social access, lack of infrastructure to
gain access to healthcare as well as lack of capital to build and
maintain proper facilities.
The Global Initiative for Childhood Cancer, announced by the World
Health Organization (WHO) aims to reach a 60% survival rate for
pediatric cancer by 2030 and this can only be done with a special focus
on cancer care in LMICs. To improve cancer care delivery systems
especially in low resource countries, a continuous quality improvement
system could help streamline existing resources for better utilization
while simultaneously improving infrastructure and caregiver knowledge.
Collaboration between institutions to identify gaps and implement local
research with careful monitoring of outcomes could also increase long
term survival.