Childhood cancer in South Africa

Prof Gita Naidu, Head of the Paediatric Oncology Unit at Chris Hani Baragwanath Academic Hospital, sheds light on the current standing of childhood cancer in SA.

Childhood is a time of innocence and joy. Yet, unfortunately, every year more than 250 000 children and adolescents younger than 20 are diagnosed with childhood cancer globally. 

According to estimates by the International Agency for Research on Cancer (IARC), almost 100 000 deaths occur annually in children and adolescents; 90% of these deaths occur in low- and middle-income countries (LMICs). Eighty percent of young cancer patients diagnosed in Africa die. Of greater concern is that many patients die from undiagnosed cancer, often with severe pain.

Poverty is a major barrier to childhood cancer outcomes

Approximately 80% of children with cancer in high income countries (HICs) survive. However, in LMICs cancer in children is often detected too late for effective treatment. Added to that, treatment is complicated by co-morbidities, such as malnutrition, HIV and AIDS, tuberculosis, affordability, and restricted access to treatment and care. 

The burden and effects of childhood cancers in LMICs are complex and multifactorial. Socio-economic status of the parents, level of parental education, vulnerability and risk, and socio-politics are some of the factors which are recognised.

Poverty affects health and mortality at all ages, but particularly in children. LMICs have poor healthcare provision, with few specialised cancer centres. Eighty percent of the African population have no access to radiotherapy, cancer surgery, basic chemotherapeutic medicine, or the infrastructure needed for basic cancer care. Unfortunately, the most important determinant of outcome for a child with cancer is where he or she is born.

Many children with cancer remain undiagnosed and unreported. This is because 80% of these children are from LMICs with weak health systems, where essential medicines are inaccessible and unaffordable. 

Even HICs are faced with the burden of childhood cancer as it’s now the leading non-communicable disease-related cause of death. In the USA, after car crashes, cancer is the second leading cause of death in children aged 1 to 14. 

Risk factors

In adults, lifestyle-related risk factors, such as smoking, being overweight, not getting enough exercise, eating an unhealthy diet, and drinking alcohol play a major role in many types of cancer. 

But lifestyle factors aren’t thought to play much of a role in childhood cancers. Radiation exposure and parental smoking has been linked to some childhood cancers, but more studies are needed to clarify these risks. 

Genetic factors influence our risks for developing certain cancers. Some children inherit DNA mutations from a parent that increase their risk of certain types of cancer. However, most childhood cancers aren’t inherited. 

The most common childhood cancers are: 

• Leukaemia
• Brain and spinal cord tumours
• Neuroblastoma
• Wilms’ tumour
• Lymphoma (including both Hodgkin and non-Hodgkin)
• Rhabdomyosarcoma
• Retinoblastoma
• Bone cancer (including osteosarcoma and Ewing’s sarcoma)

Treatment 

In HICs, most children and adolescents with cancer are treated at a university academic hospital and rarely by individual doctors. Academic units offer the advantage of being treated by a team of specialists, comprising paediatric oncologists, paediatric oncology surgeons, paediatric neuro-oncologists and surgeons, paediatric radiation oncologists, paediatric ophthalmologists, psychiatrists and pathologists. 

The team also includes paediatric oncology nurses, dedicated oncology pharmacists, dietitians, physiotherapists, occupational and speech therapists, audiologists, social workers, psychologists and play therapists. 

As our knowledge of childhood cancer has improved, it has become more evident that treatment be given by experts in this area.

Screening 

Childhood cancers are rare, and there are no widely recommended screening tests to detect cancer in children who aren’t at increased risk. 

Some children have a higher chance of developing a specific type of cancer because of certain genetics they inherit from a parent. These children may need careful, regular medical check-ups that include special tests to look for early signs of cancer.

The St Siluan Warning Signs

The Paediatric Oncology Unit at Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand has developed the St Siluan Early Warning Signs for childhood cancer. The warning signs have been endorsed by the South African Children’s Cancer Study Group and the South African Department of Health. The signs are disseminated by CHOC and CANSA. These signs are used nationally and in some LMICs.

The warning signs are:

S – Seek medical help early for ongoing symptoms.

I – White spot in the eye, a new squint, sudden blindness or bulging eyeball.

L – Lump on the stomach, pelvis, head, arms, legs, testicles or glands.

U – Unexplained fever present for over two weeks, weight loss, fatigue, pale appearance, easy bruising and bleeding.

A – Aching bones, joints, back and bones that break easily.

N – Neurological signs, such as abnormal movements, a change in walking, balance or speech, regression, continuous headaches with or without vomiting, and an enlarged or bulging head.

Complications after treatment

Most childhood cancers tend to have better outcomes than adult cancers. In recent years, there have been major advances in the treatment of childhood cancer. Therefore, more children treated for cancer survive into adulthood. 

Childhood cancers are mainly high-grade cancers and treated with intensive chemotherapeutic and radiation protocols and aggressive wide-field surgery which may result in long-term toxicities. 

The risk for side effects is related to the type and stage of cancer; the therapeutic regimen used; the age at the time of the cancer diagnosis; the nutritional status and the HIV status. Some of the possible late effects include:

• Heart, kidney or lung problems 
• Delayed growth and short stature
• Infertility and changes in sexual development 
• Learning problems
• Second malignancies

Chris Hani Baragwanath Academic Hospital

The Chris Hani Baragwanath’s Paediatric Oncology Unit serves the residents of Soweto, a peri-urban and mostly low-income township. We are the largest unit in SA and have a wide referral base, including neighbouring SADEC countries and have a strong team of caring, compassionate, and industrious individuals and are fortunate to have a committed and reliable team of surgeons, pathologists, nurses and allied health workers. We are the only unit in SA treating children and adolescents from birth to 19 years of age. 

The entire paediatric department is a beacon of hope, bringing comfort and solace to the hundreds of children we treat and their families.

The unit has two in-patient wards for children from birth to 20 years and an out-patient clinic with a day ward which offers treatment to 700 patients a month. The unit has two 10-bedroom houses, in Soweto, for children receiving out-patient therapy who can’t travel to the hospital every day.

The hospital is a teaching hospital for undergraduate and post-graduate medical students from the University of the Witwatersrand. The paediatric department trains undergraduate medical and allied health students, registrars who are training to be specialist paediatricians. 

The Paediatric Oncology Unit is an accredited unit to train paediatricians in the sub-speciality of Paediatric Oncology. We have trained paediatric oncologists for Chris Hani Baragwanath Academic Hospital, Charlotte Maxeke Academic Hospital, the first two paediatric oncologists for Kwa-Zulu Natal and currently are training the first two paediatric oncologists for Zimbabwe.

Helping hands

Many of our brave young children are alone in hospital and bear their pain and suffering on their own, for circumstances beyond their parents’ control. Fortunately, we have organisations and members of the community, to whom we are deeply indebted, who support our children and their families: CHOC, Reach for a Dream, the Stan and Daphne Nkosi Foundation, Kids Kicking Cancer, Rainbows and Smiles, Cupcakes for Hope. Plus, numerous other organisations and individuals who help our children and their families to bear their pain and suffering, and to bring hope and joy into their lives. 

Header image by Freepik