diﬀerent provinces. El Registro Oncopediátrico Hospitalario Argentino (known as ROHA) became the public national registry. This incorporation of ROHA into INC was deemed to be essential to developing evidence-based childhood cancer control.6 Coordination of international cooperation is key to foster resources and support towards a common objective. An example of this cooperation is the creation of the Global Initiative for Cancer Registry Development (GICR) led by the International Agency for Research on Cancer, with the objective of providing support to and sharing knowledge with countries to build populationbased cancer registries. The GICR has created so-called regional hubs, which provide support in building and maintaining cancer registries to surrounding countries. One of these hubs is in Buenos Aires and is coordinated by INC. These hubs facilitate collaborations from diﬀerent partners including the Operative Group on cancer registries from the Network of National Cancer Institutes (RINC), one of the six networks that are part of the South American Health Governance Institute.7 Operative groups from participating countries constitute a Latin American platform and network where countries exchange and share knowledge and expertise, as well as set up regional priorities. RINC has also commissioned a revision of information systems used to monitor cervical cancer prevention programmes in the region to allow sharing of country experiences with systems and contribute to the construction of a common set of indicators to measure programme performances. A main challenge in the implementation of cancer registries and information systems is sustainability in the long term, and for that, commitment from governments is essential. Cancer registries require
highly trained staﬀ with suitable working conditions to increase employee retention.8 Furthermore, robust government support is key to incorporate all sources of information such as data from social security and the private sector, to assure comprehensive registries. This factor is especially important in the context of Latin America, where health systems are highly fragmented, and underlies the importance of including cancer registries in national cancer control plans. Silvina Arrossi Consejo Nacional de Investigaciones Cientiﬁcas y Tecnicas/Centro de Estudios de Estado y Sociedad Area Salud, Sanchez de Bustamante 27, Buenos Aires 1193, Argentina, and National Program of Cervical Cancer Prevention, National Cancer Institute, Buenos Aires, Argentina [email protected]
I declare no competing interests. 1
Strasser-Weippl K, Chavarri-Guerra Y, Villarreal-Garza C, et al. Progress and remaining challenges for cancer control in Latin America and the Caribbean. Lancet Oncol 2015 16: 1405–38. Goss PE, Lee BL, Badovinac-Crnjevic T, et al. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 16: 391–36. Arrossi S, Paolino M, Sankaranarayanan R. Challenges faced by cervical cancer prevention programs in developing countries: a situational analysis of program organization in Argentina. Rev Panam Salud Publica 2010; 28: 249–57. WHO. Compendium of innovative health technologies for low-resource settings. Assistive devices. eHealth solutions. Medical devices. Geneva: World Health Organization, 2013. Arrossi S, Thouyaret L, Laudi R, et al. Implementation of HPV-testing for cervical cancer screening in programmatic contexts: the Jujuy demonstration project in Argentina. Int J Cancer 2015; 137: 1709–18. Moreno F, Loria D, Abriata G, Terracini B, ROHA network. Childhood cancer: incidence and early deaths in Argentina, 2000–2008. Eur J Cancer 2013; 49: 465–73. Red de Institutos Nacionales de Cáncer (RINC). El grupo operativo de registros de cáncer. Rio de Janeiro: RINC, 2015. http://www2.rinc-unasur. org/wps/wcm/connect/RINC/site/home/grupos_operativos/grupo_ operativo_de_registros_de_cancer (accessed Aug 28, 2015). Stillman FA, Kaufman MR, Kibria N, Eser S, Spires M, Pustu Y. Cancer registries in four provinces in Turkey: a case study. Global Health 2012; 8: 34.
Paul Goss and colleagues’ 2015 Commission1 has provided a detailed and highly informative account of progress in cancer control in Latin America and the Caribbean. The process carried out in this and its antecedent Commission2 2 years ago can serve as a measure of performance for governments and policy makers, cancer agencies, institutions including hospitals, health-care providers, administrators, consumers, and advocates. Moreover, the recommendations in the www.thelancet.com/oncology Vol 16 October 2015
Commission serve as a template for change in resource constrained low-income and middle-income countries. However, children, adolescents, and young adults receive somewhat scant attention in the Commission. Although the cancer burden in this age group is a small proportion of incident cases as a whole, the age distribution of the population in low-income and middle-income countries results in a greater proportion of the burden of morbidity and mortality
Developments in paediatric care in Latin America
See The Lancet Oncology Commission page 1405
from cancer in young people in this region than in high-income countries. Furthermore, with increasing survival and life expectancy in this age group in much of Latin America and the Caribbean, the potential years of life saved are substantial. However, survivors are subject to prevalent and severe late onset sequelae of treatment that impose a shortening of life expectancy. Several gains in cancer control among children and youth in this region, as in others, have been assisted by twinning—that is, linking institutions in low-income and middle-income countries with partners in high-income countries. An early example established 30 years ago is the La Mascota project, in which hospitals in Italy and Switzerland formed a close association with the Hospital Manuel Jesús de Rivera in Managua, Nicaragua. This partnership prompted the establishment of the Monza International School of Pediatric Hematology and Oncology (MISPHO), which attracted participants from 14 countries in Latin America and the Caribbean. MISPHO, held annually, led to the formation of an association between the Spanish speaking countries of Central America together with the Dominican Republic—Asociación de HematoOncología Pediátrica de Centro América (AHOPCA). AHOPCA has served as a model for collaboration among low-income and middle-income countries for more than 15 years since its introduction. Furthermore, AHOPCA has developed a network of partners in Italy, the USA, and Canada. Meanwhile, a group of South American countries (Argentina, Brazil, Chile, and Uruguay) have formed a consortium (Grupo América Latina de Oncología Pediátrica; GALOP) that is linked to the US-based Children’s Oncology Group; the largest co-operative group in the world focused on research in paediatric, adolescent, and young adult oncology. Additionally, The Centre for Global Child Health at the Hospital for Sick Children in Toronto, Canada, has engaged with six hospitals in the Caribbean to form the Sick Kids—Caribbean Pediatric Cancer and Blood Disorders Initiative. Several of the issues discussed by this Commission are of particular relevance to children with cancer in the region including access, availability, and aﬀordability with respect to drugs. Provision of government resources in the form of public health insurance is well exempliﬁed by Seguro Popular in Mexico. In particular, this system prioritises children 1402
with cancer and has achieved a remarkable increase in coverage (from 3·3% in 2006 to 55·3% in 2009) for this population through the Fund for Protection Against Catastrophic Expenditures.3 Similarly, the coverage of drugs for children with cancer in Chile has essentially become universal within the El Programa Infantil Nacional de Drogas Antineoplásicas (known as PINDA) network.4 The importance of government commitment to health-care spending is evident from a study5 in 135 countries that showed an association between average governmental health expenditure per capita in low-income and middle-income countries and the number of antineoplastic drugs for children in national essential drugs lists and national reimbursable drug lists. Moreover, the clear association of increased average governmental health expenditure per head with improved 5-year survival for children with cancer in low-income and middle-income countries has been shown in the My Child Matters programme, which includes Honduras and Venezuela.6 A further issue emphasised by the Commission that resonates in the community of paediatric oncology in Latin America and the Caribbean is early detection of disease. Important strides have been made in early detection of childhood cancers such as a successful retinoblastoma screening programme in Honduras7 which incorporated retinoblastoma screening with populationbased childhood immunisations. Malnutrition is both prevalent and severe in some parts of this region and is linked to socioeconomic disadvantage. A measure of socioeconomic status has been devised8 and has allowed interventions to redress malnutrition and improve the survival of children with acute lymphoblastic leukaemia in Guatemala. The Commission also highlights the need for investment in the education of health-care professionals in oncology. Several countries are responding to this need, such as Guatemala, which has devised a programme for oncologists in Guatemala City that attracted 25 trainees from eight countries in the region.9 Such investments are essential to develop the discipline of paediatric oncology. Similarly, participation in clinical trials is also crucial to building a paediatric knowledge base in the region, and collaborations between GALOP with the Children’s Oncology Group,10 are addressing this need. Cancer control relating to children, adolescents, and young adults in Latin America and the Caribbean is www.thelancet.com/oncology Vol 16 October 2015
undergoing substantial progress but vigilance is needed to continue to invest in the health care of its youngest and most vulnerable citizens.10 Ronald Barr Department of Pediatrics, Division of Hematology-Oncology, McMaster University, Ontario L8S 4J9, Canada [email protected]
I declare no competing interests. 1
Strasser-Weippl K, Chavarri-Guerra T, Villarreal-Garza, et al. Progress and remaining challenges for cancer control in Latin America and the Caribbean. Lancet Oncol 2015; 16: 1405–38. Goss PE, Lee BL, Badovinac-Crnjevic T, et al. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14: 391–36. Pérez-Cuevas R, Donbova SV, Zapata-Tarres M, et al. Scaling up cancer care for children without medical insurance in developing countries: the case of Mexico. Pediatr Blood Cancer 2013; 60: 196–203. Campbell M, Salgado C, Quintana J, et al. Improved outcome for acute lymphoblastic leukemia in children of a developing country: results of the Chilean National Trial PINDA 87. Med Pediatr Oncol 1999; 33: 88–94.
Barr R, Robertson J. Access to cytotoxic medicines by children with cancer: A focus on low and middle income countries. Pediatr Blood Cancer 2015; published online Sept 16. DOI:10. 1002/pbc.25722. Ribeiro RC, Steliarova-Foucher E, Magrath I, et al. Baseline status of paediatric oncology care in ten low income or mid-income countries receiving My Child Matters support: a descriptive study. Lancet Oncol 2008; 9: 721–29. Wilimas JA, Wilson MW, Haik BG, et al. Development of retinoblastoma programs in Central America. A model for building regional centers of excellence for pediatric cancers. Pediatr Blood Cancer 2009; 53: 42–46. De Pernillo M, Rivas S, Fuentes L, Antillon F, Barr RD. Measurement of socio-economic status in families of children with cancer in Guatemala. Pediatr Blood Cancer 2014; 61: 2071–73. Barr RD, Antillon-Klussman F, Baez F, et al. Asociación de Hemato-Oncología Pediátrica de Centro-América (AHOPCA): a model for sustainable development in pediatric oncology. Pediatr Blood Cancer 2014; 61: 345–54. Rodriguez-Galindo C, Friedrich P, Alcasabas P, et al. Toward the cure of all children with cancer through collaborative eﬀorts: pediatric oncology as a global challenge. J Clin Oncol 2015; 33: 3065–73.
Cancer control in the English-speaking Caribbean The global burden of non-communicable diseases (NCDs), and of cancer in particular, is expected to increase substantially over the next 20 years, particularly in the developing world.1 Generally ranked as low and middle income, the countries of the English-speaking Caribbean are island nations, with the exception of Guyana (located on the north coast of South America). With populations varying from 15 000 in Anguilla to 2·7 million in Jamaica, these countries are a heterogeneous group better known as tourist destinations than as places where NCDs are rife. Barbados, Trinidad and Tobago, and Jamaica rank as the top three countries with the highest prevalence of NCDs in adults in the Americas, and cancer is the second leading cause of death overall across the region.2 In September, 2007, in response to an increase in obesity and increasingly high mortality from cardiovascular disease and cancer, the Caribbean Community (known as CARICOM) convened to address NCDs. This meeting resulted in the Port of Spain declaration entitled Uniting To Stop The Epidemic Of Chronic Non-Communicable Diseases,3 and subsequently, to the development of the Strategic Plan of Action for the Prevention and Control of Non Communicable Diseases for Countries of the Caribbean Community in conjunction with the Pan American Health Organization (PAHO) and WHO.4 The awareness of the cancer epidemic in the region was www.thelancet.com/oncology Vol 16 October 2015
increased when it was noted that the risk factors for many cancers were the same as those for NCDs. The problems with cancer control that beset these island nations are strikingly similar to those experienced by their larger Latin American neighbouring countries; issues which are well elucidated in The Lancet Oncology’s 2015 Commission.5 These concerns include: disproportionately low health care budgets, health care disparities, poor infrastructure, a dearth of cancer treatment facilities, inadequate human resources, and the absence of resources for education and training in oncology and palliative care. Cancer mortality in these island nations is similar to those in other Latin American countries with prostate, colorectal, and lung cancer predominating in men, and breast, colorectal, and cervical carcinoma in women. The proportion of stomach and liver cancers in both sexes is also high.6 A substantial percentage of people in the Caribbean present with advanced disease, because poor education, fear of medical professionals, and deeply embedded cultural myths about cancer prevent people from seeking help early.7 Even when patients do present early, diagnostic and laboratory services are often overstretched and histopathological diagnosis can take months. These delays are then compounded by inadequate treatment facilities and waiting times to begin treatment, particularly for radiation treatment, which can extend to half a year or more.
See The Lancet Oncology Commission page 1405