Paediatric Oncology in Tonga

Background on Tonga Tonga’s population: 103,252 73% live on main island. Proportion <15yo- 38,457 (37.2%) Vaiola is the one main hospital for the kingdom We have ~120 admissions per month to our paediatric ward ~2,500 deliveries/year Infant mortality 11-16/1000 live births A little background of our setting in Tonga We admit patients <14 years in Tonga.

Paediatric Services in Tonga 1 Paediatrician 3 Registrars Interns 4 oncology nurses (1 new recruit) 2 trained have left 34 bed paediatric ward 11 bed SCN *Only 2 doctors giving chemotherapy currently

Pic of ward

Paediatric Oncology In Tonga Disease burden is approx. 5 cases annually or 140 per million population < 14years old. Most oncology cases are diagnosed.* Supportive services- -Radiologist (CT scan) -Pathologist -Surgical team *We do face the problem of delayed diagnosis as a lot of families seek alternate medicine before coming to the hospital, or have had multiple presentations to OPD and diagnosis is missed. Occasionally they will present too unwell and there is no chance to confirm diagnosis before they pass away.

We did an audit looking at malignancies over a 5 year period of 2009-2013…..these were the malignancies found over that 5 year period…..there were 25 altogether…. ALL is the most common haematological malignancy, we did have a few AMLs…………...we had 4 non hodgkins lymphomas of which 2 were Burkitts lymphoma. Ive separated them out here on the graph. And then there were a number of brain tumors. Out of the bone cancers, Ewings was more common than Osteosarcomas over this period. ‘others’------ 2 year old boy who had a sclerosing variant of rhabdoid tumor of his left kidney, which was initially thought to be a Wilms tumor.

Majority of the malignancies over this 5 year period were haematological cancers……..with nervous systems malignancies coming in second……..and then we have the bone cancers and others.

Majority of our oncology cases are male………there were only females in brain tumors, Ewings sarcoma and ALL cases, the rest of the malignancies occurred in males.

The age distribution of our malignancies over this 5 year period showed a majority occurring under 5 years old, and in the older age group of 10-14 years. These age groups have been adjusted to take into account total population of the specific ages in Tonga.

Cancers considered for treatment in Tonga Leukemias- only ALL Lymphomas- most considered, except Hodgkins advanced stage1V and some NHL. Wilms Retinoblastoma Neuroblastomas considered except stage 3 and 4 Germ Cell tumours *Brain Tumours, soft tissue and bone sarcomas are generally not considered for referral for treatment unless surgically resectable. Cancers who are offered referral for treatment in Tonga are these…...this is guided by the referral guidelines set up by the Pacific Oncology steering group in 2008…..we started using tis is 2009……….it has provided consistency in who gets referred for treatment given our limited budget. …..only ALL out of the leukemias. Brain Tumors and the soft tissue and bone sarcomas are generally NOT considered for referral for treatment because prognosis is not as good and the cost of treatment is prohibitive………And even if they are surgically resectable, the prognosis is still poor. For Lymphomas, most are considered for treatment…………………except advanced stage 4 hodgkins, and some non hodgkins lymphomas (such as lymphocytic lymphoma)…….Burkitts Lymphoma however…….is very sensitive to chemotherapy and is therefore considered for treatment…..

Looking at those referred over a 5yr period…… Looking at those referred over a 5yr period…….Just a little over 50% of the malignancies were referred overseas……some were for diagnostic purposes, such as neuroimaging in suspected brain tumors……. 40% of the cases were referred for treatment. Half of the cases were not sent for treatment, in accordance to our referral protocol.

…..60% have achieved remission and 30% relapsed despite treatment.

Breaking down the outcomes to specific malignancies……… Breaking down the outcomes to specific malignancies……….The Hodgkins Lymphomas have done very well. Ewings sarcoma case is a miracle case……had metastasis to lungs on CT in NZ but repeat scans upon return have been clear to date!!

Current Oncology practice We follow the PI ALL-2 protocol. We carry out the Interim maintenance phase, delayed intensification, and continuous maintenance phase in Tonga now.* We also do the last 4 months of the Hodgkins treatment protocol and have experience in giving the last month of Retinoblastoma treatment. We get excellent support from Dr Jane Skeen and the team from Starship Hospital. *A.L.L patients get their pre-phase treatment in Tonga then they travel to NZ to have the more intensive parts of the treatment protocol done (Induction phase and the CNS prophylaxis and consolidation phase)……They then return to Tonga for the Interim maintenance, delayed intensification, and continuous maintenance. ……It was only this year that we started doing the interim maintenance and delayed intensification phase in Tonga. …………. ……..We are slowly taking up more of the treatment process as we are now more capable to do this……. with training of our doctors and nurses and very good support from Drs Jane Skeen and Bridgette from Starship Hospital. This has helped save a lot of the cost for sending our patients abroad for treatment.

Looking at the treatments given and the outcomes……………... Majority of our cases are offered palliative care as they do not meet criteria for referral for treatment…….As you would expect, they have passed away. 62% of our patients that went through chemotherapy did achieve remission.

The overall outcome of malignancy cases over the 5 year period……there is a high mortality rate……this reflects the nature of the disease and our selection criteria used when offering treatment.

Paediatric Oncology in Tonga Survival rates of cases referred for treatment so far looks favourable. Overall mortality is high, largely resource issue. Our team has limited experience with providing chemotherapy locally but we’re making good progress with the support from Starship Hospital, NZ. ……60% remission……. This is a good outcome considering our circumstances and resources…..but we accept it is very short follow up at this stage. …….. largely attributed to the nature of the particular malignancy and our limited resources.

Challenges Biggest challenge is awareness and early presentation of cases. Dealing with those who do not fit referral criteria, in terms of accepting diagnosis and palliative care. Central line maintenance (portacaths, PICC lines) Occasionally have delay in confirmation of diagnosis from lab, but good collaboration via Starship Oncology and Labplus. And as you’ve noted, there are quite a number of cases that received palliative care, and more effort needs to be made to provide better quality palliative care for these children. …..we do not have enough dedicated oncology nurses to cover all shifts.

Way forward: Need regular training and support from Starship Oncology team. Review existing guidelines whether more malignancies can be added to our referral guidelines. Also more treatment could be delivered locally as we grow the local capability to do so. Long term follow up of those in remission* *……….Dr Jane Skeen comes every year for visits and follow up our oncology cases……ensuring monitoring for long term effects of chemotherapy and also for secondary malignancies to ensure good quality of life for those who survive.

THANK YOU