1. Comprehensive Care in Pediatric Cancer Patients Comprehensive Care in Pediatric Cancer Patients Dr. Salah S. Abdel Hadi Professor, Pediatric Oncology NCI, Egypt

2. Introduction Cancer in children & adolescents is rare. Cancer in children & adolescents is rare. Children & adolescents with cancer should be referred to tertiary care centers where multi-disciplinary care is available. 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 Treatment, supportive care & rehabilitation are offered to achieve: a) optimal survival. b) quality of life

3. Introduction Pediatric cancer management is one of the success stories of modern medicine. 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. 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. There is a life time saved for every child cured of cancer.

4. Introduction Cancer in children is a significant problem of mortality in developed countries. 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). 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. In developing countries, cancer trails infections as a cause of mortality; but continues to rise within list of priorities as infections become controlled.

5. Introduction Malignancies in childhood occur with an incidence of 13-14 per 100,000 children. Malignancies in childhood occur with an incidence of 13-14 per 100,000 children. Of the world’s population of 6 billion, Of the world’s population of 6 billion, 650 million reside in developed countries with older populations/smaller fraction of children. 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 number of new cases annually exceeds 200,000 world wide. The proportion of new cases in developing countries currently at about 85% and rising. The proportion of new cases in developing countries currently at about 85% and rising.

6. Introduction The population of developing countries represented 78% of the global total in 1990. 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. Countries with limited resources accounted for 86% of the world’s children in 1990. “Projected to increase to more than 90% by 2030”. “Projected to increase to more than 90% by 2030”. The major killers of children in countries with limited resources remain: The major killers of children in countries with limited resources remain: a) infections b)malnutrition a) infections b)malnutrition c)diarrhea/dehydration. c)diarrhea/dehydration.

7. Introduction However there is an increase in the relative importance of cancer in the spectrum of disease in childhood in some developing countries. 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. 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 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

8. Priority of Oncology Problem In Egypt Pediatric oncology on the rise. Pediatric oncology on the rise. Control of acute illnesses in pediatrics. Control of acute illnesses in pediatrics. Success of vaccination program. Success of vaccination program. Population increase (1.8million births/year). Population increase (1.8million births/year). Better diagnostic facilities & know how. Better diagnostic facilities & know how. Improving patient survival. Improving patient survival. Increasing specialized care centers. Increasing specialized care centers.

9. Outlets for Pediatric Oncology Service In Egypt Universities (14 governmental & private) Universities (14 governmental & private) Departments of pediatrics: liquid malignancies Departments of pediatrics: liquid malignancies Departments of radiation oncology: solid tumors Departments of radiation oncology: solid tumors Cancer institutes Cancer institutes National cancer institute, Cairo University National cancer institute, Cairo University South Egypt Cancer Institute, Assiut University South Egypt Cancer Institute, Assiut University Ministry of Health Ministry of Health Nasser Institute Nasser Institute Cancer Centers Cancer Centers Armed Forces and Police hospitals Armed Forces and Police hospitals Private Sector Private Sector

10. Background Background Chemotherapy was introduced to treat childhood leukemia in 1940s. Chemotherapy was introduced to treat childhood leukemia in 1940s. Prognosis of childhood cancer dramatically improved over the years. Prognosis of childhood cancer dramatically improved over the years. 5 year survival (diseases uniformly fatal in chemotherapy era) = 75% for all childhood 5 year survival (diseases uniformly fatal in chemotherapy era) = 75% for all childhood cancer diagnosed between 1989 and 1995. cancer diagnosed between 1989 and 1995. Multi modality approach becomes standard in managing most childhood cancers. Multi modality approach becomes standard in managing most childhood cancers.

11. Principles Pharmacologic interventions in most cases “anti- hypertensives” administered with intent of controlling disease/symptoms rather than cure. Pharmacologic interventions in most cases “anti- hypertensives” administered with intent of controlling disease/symptoms rather than cure. Exception lies in anti microbial and anti cancer chemotherapy. Exception lies in anti microbial and anti cancer chemotherapy. The model for curing cancer is based on successful model of curing bacterial infections. The model for curing cancer is based on successful model of curing bacterial infections.

12. Principles (cont.) The strategy exploits differences between cancer and normal cells attempting to eradicate or kill cancer cells. 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. 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 anti- cancer drugs produce substantial clinical toxicity. This method identified drugs that are cytotoxic and non selective. Most conventional anti- cancer drugs produce substantial clinical toxicity.

13. Management Protocol treatment Protocol treatment Tumor boards Tumor boards Referral attitudes (tertiary care center) Referral attitudes (tertiary care center) Team approach Team approach First chance is best chance and only chance of cure. First chance is best chance and only chance of cure.

14. Protocol Approach Patients treated on protocol do better than individually managed. Patients treated on protocol do better than individually managed. Thesis approach vs. protocol approach Thesis approach vs. protocol approach The Indian experience The Indian experience Controversies of unifying protocols Controversies of unifying protocols Upgrading of participating centers Upgrading of participating centers Development of two protocols Development of two protocols Referral of patients during intensive management. Referral of patients during intensive management.

15. Team Approach Shift from: - unipolar (doctor, leader & remaining followers) to Shift from: - unipolar (doctor, leader & remaining followers) to - multipolar (teams of specialized professionals working in harmony) - multipolar (teams of specialized professionals working in harmony) Development of trained professionals in: Development of trained professionals in: a) data management a) data management b) infection control, b) infection control, c) terminal care c) terminal care

16. Infection Control Infection Control Education Education fever/neutropenia - vaccinations fever/neutropenia - vaccinations Nosocomial infections Nosocomial infections infection control committees infection control committees micro biological surveys micro biological surveys Hepatitis Hepatitis national level national level hepato toxic agents hepato toxic agents management slip ups management slip ups

17. Compliance Compliance Education: Education: child - society child - society family - medical milieu. family - medical milieu. Team approach Team approach doctor - clinical pharmacist doctor - clinical pharmacist nurse - dietitian nurse - dietitian social worker - play therapist social worker - play therapist Proper/practical dealing of Proper/practical dealing of - fears - mis-concepts.

18. Late Sequelae Late Sequelae Proper choice of chemotherapy: Proper choice of chemotherapy: Agents Agents protocols protocols Avoidance of management by combined chemo/radiotherapy. Avoidance of management by combined chemo/radiotherapy. Avoidance of radiation therapy in early childhood “deferred rth. in brain tumors” Avoidance of radiation therapy in early childhood “deferred rth. in brain tumors” Avoidance of mutilative surgery Avoidance of mutilative surgery Early and aggressive rehabilitation Early and aggressive rehabilitation

19. Information Deficits Information Deficits Development of national registry Development of national registry Development of institutional data basis Development of institutional data basis Development of: Development of: data management facilities data management facilities data managers data managers research nurses. research nurses. Development of multi center studies. Development of multi center studies. Prospective Prospective Randomized Randomized Double blind Double blind

20. Integration in Society Integration in Society Education/rehabilitation Education/rehabilitation Psychosocial adaptation Psychosocial adaptation Job/career opportunities Job/career opportunities Late effects committees in collaboration with medical oncology Late effects committees in collaboration with medical oncology