The Changing Faces of Childhood Cancer Care at Kanti Children’s Hospital

Children with different types of childhood cancers have been undergoing chemotherapy at Kanti Children’s Hospital since many years. The initiation of chemotherapy dates back to about two decades when chemotherapy was provided to the children in the general medical ward.In the initial phases of oncology services there were no specific protocols of treatment for the different childhood cancers. Specific single arm protocols of treatment were introduced in B.S. 2054 for leukemias, lymphomas and some of the more common solid tumors. There was none or very little risk stratification of the treatment protocols. The common oncological problems were: ALL, AML, CML, Hodgkin’s and non-Hodgkin’s Lymphomas, Wilm’s tumor, Retinoblastoma, Neuroblastoma, Rhabdomyosarcoma, germ cell tumors. The different childhood cancers treated at Kanti children’s Hospital during the last five years were as follows:

ALL=acute lymphoblastic leukemia; AML=acute myelogenous leukemia; CML=chronic myelogenous leukemia; NHL=non-Hodgkin’s lymphoma; HD=Hodgkin’s disease; WT=Wilm’s tumor; RMS= rhabdomyosarcoma; RBL=retinoblastoma; NBL= neuroblastoma; GCT=germ cell tumors

There are at present two adequately trained pediatric oncologists , a pediatrician and a medical officer as well as a team of nurses and supportive staff, who have dedicated themselves to the welfare of the children with cancers and their families. Besides routine laboratory tests being available at the hospital and other locations in Kathmandu, the oncology unit is also equipped with a flow cytometer for immunophenotyping back up and more accurate diagnosis and monitoring of childhood cancers. A deficit of trained manpower (doctors, nurses, pathologists, radiotherapists, and other supporting manpower), shortages of medicines in the market, lack of facilities for radiotherapy, CT and MRI scans, central venous lines, lack of facilities for adequate histology, cytology, karyotyping, cytogenetics, FISH,PCR, immunohistochemistry and other laboratory markers of childhood cancers are some of the constraints faced by the oncology unit at Kanti ChildrenThe funds available in the unit are not enough to satisfy many of the genuine needs of the increasing number of patients and their families. All the patients that need stem cell transplantation have had to be referred to other countries. It is important that childhood cancer registration be maintained more actively and a multi-disciplinary approach be instituted at the hospital to ensure optimal results in cancer care in children.

Treatment of children with childhood cancers at Kanti Children’s Hospital have been conducted in close collaboration with the pathologists, pediatric surgeons, radiotherapy units of Bir Hospital and Bhaktapur Cancer Hospital, the Tribhuban University Teaching Hospital. At present chemotherapy in the oncology ward at Kanti Children’s Hospital is being conducted in accordance with recent standard protocols brought in from the US, UK and India. The different childhood cancers are risk stratified into low risk, intermediate risk, high risk and very high risk on the basis of the age of the child, different laboratory parameters, and morphology/histology of the examined specimens, radiological findings and staging at surgery. Despite the limited resources and different constraints standard protocols of treatment are applied to suit the risk stratification so as to obtain maximal overall- and event-free survival with minimal events( grade 3-4 toxicities, deaths, relapse or second malignant cancers) while at the same time ensuring optimal quality of life. Taking into account the high cost of the treatment and the socio-economic and mental burden on the patient and their families, funds have been established from donations from generous national and foreign donors to support the unit and help the patients and their families get through their treatment smoothly .The treatment of most of the patients have been supported from these funds, many times completely in poorer patients.

1. 9% of the patients have completed their chemotherapy and 47.8% of the total number of patients is in follow up. The obvious mortality was 14.3%. A large number of patients are lost to follow up and comprise 37.9%. To summarize, the following aspects of a multidisciplinary approach to optimal cancer care for the children should be addressed:
2. We need to alleviate the challenges we face in the prompt diagnosis, risk stratification and treatment and monitoring of the various childhood cancers. Although we have authentic protocols to treat our children with cancers, supportive care needs to be adequately improved to obtain optimal results in outcomes and reduction of events. Increasing and strengthening the physical facilities of the oncology unit as well as the hospital to provide acceptable standards of care to our patients, typical of a tertiary care centre, are essential.
3. Pediatric oncology in our country is important because a large chunk of our population comprises children. Because children cannot speak for themselves, it becomes our responsibility as their guardians to speak for them to provide them with the best care and secure their future.
4. The burden on our efforts to provide optimal cancer care to our children is increased due to patient poverty and ignorance as well as the limited resources with the geo-political and socio-economic drawbacks we have. Hence, a large number of our patients were lost to follow up and comprise 37.9% while 11.8% of the patients were compelled to leave against medical advice and another 11.1% were compelled to drop out of treatment due to various constraints. Many of the patients arrived in the hospital in the late stages of their cancers with multiple complications. Hospital mortality was higher in these patients; many expired even before the institution of the actual chemotherapy.
5. Institutional and population-based epidemiology and registration of childhood cancers should be more intensively instituted to appropriately analyze the data available for efficient planning, implementation, monitoring and interventions in childhood cancers.
6. A large number of our patients are lost to follow up or have interrupted treatment due to different reasons. Appropriate counseling and mechanisms of follow up should be strengthened. The oncology unit of this hospital is grateful to all the national and international institutions and individuals, who have directly or indirectly contributed to the development of this unit and the welfare of the children with cancers and blood diseases here. The oncology unit of this hospital with the following dedicated staff needs to be congratulated for their continued hard work to provide the best possible care to the children with cancers in our country.