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 »  Abstract
 » Background
 »  The Burden of Pe...
 »  Why Has Pediatri...
 »  Why Should We Fo...
 »  What are the Ris...
 »  Pediatric Cancer...
 »  Palliative Care ...
 »  What is the Path...
 » Conclusion
 »  References
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  Table of Contents  
Year : 2021  |  Volume : 58  |  Issue : 2  |  Page : 285-289

Cancer in children: The tip of the iceberg

Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India

Date of Submission15-Jul-2020
Date of Decision15-Jul-2020
Date of Acceptance13-Sep-2020
Date of Web Publication11-May-2021

Correspondence Address:
Venkatraman Radhakrishnan
Department of Medical and Pediatric Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_787_20

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 » Abstract 

Pediatric cancer outcomes have improved dramatically in high-income countries (HICs) with more than 80% of patients surviving. This has been achieved through early diagnosis, the formation of collaborative research groups, and government policies. However, most children with cancer in low and middle-income countries (LMICs) do not survive due to multiple factors including lack of resources, manpower, and national level pediatric cancer policy. If we need to improve the overall outcome of children with cancer then we need to focus our attention on children in LMICs as they constitute 80% of the worldwide disease burden. This article looks at the burden of pediatric cancer, examines pediatric oncology policy paralysis, and offers possible solutions for improving care for children with cancer.

Keywords: Pediatric cancer, outcome, LMIC

How to cite this article:
Radhakrishnan V. Cancer in children: The tip of the iceberg. Indian J Cancer 2021;58:285-9

How to cite this URL:
Radhakrishnan V. Cancer in children: The tip of the iceberg. Indian J Cancer [serial online] 2021 [cited 2022 May 19];58:285-9. Available from:

 » Background Top

“Amma (mother), will this doctor make me alright,” were the feeble words that came out of the soul of a frail and scared 5-year-old girl whose eye tumor had ruptured and ballooned out of her orbit and was bleeding. Unfortunately, this is not an unusual occurrence in the day of a pediatric oncologist working in low- and middle-income countries LMICs like India.[1]

One of the greatest scientific achievements in the last half a century has been the dramatic improvement in survival in pediatric cancer from a dismal 10% to 80–90%. However, this success story of modern times has been limited to 20% of children with cancer in the developed world. The remaining 80% of children with cancer who live in developing countries are yet to see the full benefits of this success.[2],[3] Why is that the place of birth of a child with cancer determines his or her chance of survival? Why do most children in LMICs with cancer present with advanced disease and have a dismal prognosis? The reasons are multifactorial and complex as discussed below [Figure 1].
Figure 1: The pediatric cancer divide

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 » The Burden of Pediatric Cancer Top

We don't have an accurate estimate of the number of children being diagnosed with cancer every year in the world, the reason being that the data doesn't exist.[4] It was estimated that 200,000 children were diagnosed with cancer every year but in 2019 this number doubled to 400,000 per year based on modeling projections by Ward et al.[5] A paucity of registries in LMICs coupled with absent or minimal and unreliable data are the major reasons why it is difficult to quantify the true burden of pediatric cancers.[4],[5]

 » Why Has Pediatric Cancer Lagged? Top

Pediatric cancers contribute to less than 1% of the under-5 mortality rate (U5MR) and unlike common infectious diseases, they require multidisciplinary management, higher financial resource allocation, good infrastructure, and diagnostic facilities.[3] Therefore, pediatric cancers have remained out of the radar of governments and non-government organizations (NGOs) in LMICs as they were not seen as an investment worth the time and effort.[6]

The United Nations envisaged the 8-point millennium development goals (MDG) in 2000 for the betterment of Mankind. The MDG point-4 was to reduce the U5MR by two-thirds between 1990 and 2015.[7] Infections and neonatal deaths have been the biggest contributor towards the U5MR in LMICs. Therefore, the efforts of the government and NGOs over the last 3 decades have been focused on diseases like pneumonia, diarrhea, malnutrition, malaria, and human immunodeficiency virus (HIV). These efforts have borne fruits as seen by the reduction in U5MR by nearly half from 10.8 million deaths a year in 2000 to 5.6 million deaths in 2016.[7],[8],[9] However, as the U5MR is reducing in most countries the incidence of childhood cancer and mortality is increasing, alluding to the improvement in healthcare in these countries with early detection and reporting of cases.[2]

 » Why Should We Focus on Pediatric Cancers? Top

It is a misconception that pediatric cancers are expensive to treat and investing in pediatric cancers does not provide bang for the buck.[10] Studies have shown that treating pediatric cancer is cost-effective as per the World Health Organization (WHO) cost-effectiveness criteria. A recent publication by Force et al. reported that pediatric cancers were associated with the highest disability associated life years (DALYs) among all cancers. Most of the DALYs were contributed by LMICs and early deaths accounted for 99% of the DALYs.[11] The contribution of long-term disability due to the treatment of cancer in developing countries remains underestimated due to a lack of data. Pediatric cancers were 6th in position for DALYs when all common pediatric diseases were considered.

 » What are the Risk Factors for Poor Outcomes in LMICs? Top

Unlike in adults where 70% of the cancers are associated with an underlying risk factor like tobacco, alcohol, lifestyle, and diet, there are no known risk factors for most pediatric cancers. Therefore, the focus in pediatric oncology must be on early diagnosis and treatment rather than on screening and prevention. The risk factors for outcomes in pediatric cancers in LMICs are not only clinical but social, economic, and political. The risk factors, their assessment, and possible solutions are provided in [Table 1].
Table 1: Risk factors, assessment, and solution for pediatric cancers

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 » Pediatric Cancer Scenario in India Top

Data from population-based registries suggest that pediatric cancer account for 3–5% of the million new cancer cases diagnosed every year in India.[17],[18] Therefore, it is estimated that about 30,000–50,000 new pediatric cancer cases are diagnosed yearly in India.[17],[18] However, the incidence could be higher because many children with cancer do not get diagnosed or reach hospitals, cancer registries cover only 15% of the population and are mostly urban-based and cancer is not a notifiable disease.[19],[20] Pediatric cancers have not been a priority for successive governments as seen by the fact that it is not part of the National Cancer Control Program of India.[21] Pediatric cancers do not even get a mention in the national cancer policy.[21] This void has been filled by professional societies like the Pediatric Hematology-Oncology (PHO) - Chapter of the Indian Academy of Pediatrics (IAP) and NGOs.

The Indian National Pediatric Oncology Group (InPOG) which is a part of the IAP PHO chapter was established in 2008 to develop multicenter research in pediatric cancer on the lines of international pediatric research groups like the Children's Oncology Group.[22] There are currently 31 studies in the InPOG portfolio. It is expected that InPOG studies will help in addressing problems unique to resource-limited settings and help in capacity building for better delivery of patient care.

Outcomes comparable to HICs have been reported in pediatric cancers like Hodgkin Lymphoma, Wilms tumor, Germ Cell Tumors, and bone tumors from India and other LMICs.[23],[24],[25] However, outcomes in acute leukemia, neuroblastoma, rhabdomyosarcomas, and brain tumors remain inferior compared to HICs due to infection-related mortality, treatment-related toxicity, lack of access to the standard of care of treatment, and advanced stage of presentation.[23],[26],[27] Research and resources need to be directed to bridge the survival gap between HICs and LMICs. Risk-adapted protocols have been developed for many pediatric cancers by the Pediatric Oncology in Developing Countries (PODC) subcommittee of the International Society of Pediatric Oncology (SIOP) to improve outcomes by reducing deaths due to treatment-related adverse effects.[23],[28]

 » Palliative Care and Psycho-Oncology Services Deserve More Attention Top

The WHO recommends integrating palliative care at diagnosis in children with cancer.[29] A systematic review of pediatric palliative care services in HICs reported that only 54.5% of children with cancer received any palliative care before death.[29] Pediatric oncology palliative care services are non-existent in most LMICs.[3] The need for palliative care services is vital in LMICs as the majority of children with cancer present with advanced disease and a significant proportion of them will die due to cancer. Barriers to implementation of palliative care services include perceived cost, lack of enough time, non-availability of trained professionals, provider discomfort with palliative care conversations, and misconceptions regarding palliative care as only beneficial when treatment is no longer effective.[3],[30] Access of opioids especially morphine for pain control in children with cancer should be prioritized. The recently published Lancet Oncology commission on sustainable care of children with cancer has set a goal of achieving palliative care to 80% of children with cancer, and pain control to 100% of children with cancer by 2030 in LMICs.[3]

Children with cancer and their caregivers experience significant physical and psychological symptoms during their treatment and follow-up.[31] Some of the major symptoms include pain, anxiety, depression, and stress. It is, therefore, essential to address these symptoms by integrating psycho-oncology services into mainstream pediatric cancer services. Provision of psychosocial services for caregivers of children with cancer at the Tata Memorial Hospital Mumbai has helped in reducing treatment abandonments and thereby improve outcomes.[3]

 » What is the Path Ahead? Top

Children with cancer have been given a raw deal for decades by the major stakeholders.[3] However, things have changed rapidly in the last couple of years. In September 2018, the WHO launched the Global Initiative for Childhood Cancer to achieve at least 60% cure for childhood cancer across the world by 2030.[32] This task is humungous as we have only a decade to double the survival of childhood cancers. Achieving this target will save one million lives. St Jude hospital is playing a vital role in this effort by partnering with WHO.

India accounts for 1/5th of the world's population and 20% of newly diagnosed pediatric cancers. The Government of India does not have a formal pediatric cancer policy. However, major strides have been achieved in access to healthcare for children with cancer in the last couple of years. The introduction of the universal free healthcare scheme called the “Ayushman Bharat” by the Government of India recently has provided a well-needed impetus for treating children with cancer.

The survival of children with acute lymphoblastic leukemia (ALL) in China was less than 10% a decade back. However, this has improved to 93% today with the intervention of the government by providing free treatment to all children with ALL and due to the efforts of St Jude hospital which was instrumental in convincing the Chinese Government to make a change.[33]

[Figure 2] is a proposed health system framework to address issues at multiple levels to improve outcomes in pediatric cancer. The framework for each level is not mutually exclusive and a point of implementation can span multiple levels. For example, collaborative research can occur at individual, hospital, national, and international levels.
Figure 2: Health systems framework for improving outcomes in pediatric cancer

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 » Conclusion Top

The time has come for governments, NGOs, global organizations, and other stakeholders to invest their resources for children with cancer. We need to end this disparity and inequality where one child with cancer can access the latest chimeric antigen receptor T (CART)-cell therapy and the other cannot even reach the hospital. If we act today, we can save the lives of millions of children with cancer who then can live beyond the “dawn of their life” and be valuable members of society.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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Rodriguez-Galindo C, Friedrich P, Alcasabas P, Antillon F, Banavali S, Castillo L, 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.  Back to cited text no. 2
Atun R, Bhakta N, Denburg A, et al. Sustainable care for children with cancer: A Lancet Oncology commission. Lancet Oncol 2020;21:e185-224.  Back to cited text no. 3
Bhakta N, Force LM, Allemani C, Atun R, Bray F, Coleman MP, et al. Childhood cancer burden: A review of global estimates. Lancet Oncol 2019;20:e42-53.  Back to cited text no. 4
Ward ZJ, Yeh JM, Bhakta N, Frazier AL, Atun R. Estimating the total incidence of global childhood cancer: A simulation-based analysis. Lancet Oncol 2019;20:483-93.  Back to cited text no. 5
Rodriguez-Galindo C, Friedrich P, Morrissey L, Frazier L. Global challenges in pediatric oncology. Curr Opin Pediatr 2013;25:3-15.  Back to cited text no. 6
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  [Figure 1], [Figure 2]

  [Table 1]


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