title: Protocol-based treatment for children with cancer in low income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)--part II.
abstract: Pediatric cancer programs in low-income countries (LIC) can improve outcomes. However, treatment must be tailored to the patient's living conditions and the availability of supportive care. In some cases, a more intense regimen will decrease survival since the increase in death from toxicity may exceed any decrease in relapse. Attempts to practice evidence-based pediatric oncology are thwarted by the lack of evidence derived from local experience in LIC to determine optimal therapy. This report summarizes treatment regimens used by pediatric oncologists from 15 countries of the Caribbean, Central and South America who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with hepatoblastoma, Wilms tumor, and histiocytosis treated on unmodified published protocols had outcomes comparable to those in high-income countries (HIC). Those with rhabdomyosarcoma, osteosarcoma, Hodgkin lymphoma, and acute myeloid leukemia treated with unmodified regimens had event-free survival estimates 10%-20% lower than those reported in HIC due to higher rates of toxic death, abandonment of therapy, and relapse. Treatment of retinoblastoma is complicated by advanced stages and extraocular disease at diagnosis; improved outcomes depend on education of pediatricians and the public to recognize early signs of this disease. Use of unmodified protocols for Burkitt lymphoma and acute lymphoblastic leukemia have been associated with unacceptable toxicity in LIC, so MISPHO centers have modified published regimens by giving lower doses of methotrexate and reducing use of anthracyclines. Despite the use of all-trans-retinoic acid during induction for acute promyelocytic leukemia, the incidence of fatal hemorrhage remains unacceptably high.
authors.affiliation: International Outreach Program and Department of Hematology/Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA. Scott.howard@stjude.org
authors.forename: Scott C
authors.initials: SC
authors.lastname: Howard
authors.forename: Roberta
authors.initials: R
authors.lastname: Ortiz
authors.forename: Luis Fulgencio
authors.initials: LF
authors.lastname: Baez
authors.forename: Ricardo
authors.initials: R
authors.lastname: Cabanas
authors.forename: José
authors.initials: J
authors.lastname: Barrantes
authors.forename: Ligia
authors.initials: L
authors.lastname: Fu
authors.forename: Armando
authors.initials: A
authors.lastname: Peña
authors.forename: Angélica
authors.initials: A
authors.lastname: Samudio
authors.forename: Martha
authors.initials: M
authors.lastname: Vizcaino
authors.forename: Carlos
authors.initials: C
authors.lastname: Rodríguez-Galindo
authors.forename: Ronald D
authors.initials: RD
authors.lastname: Barr
authors.forename: Valentino
authors.initials: V
authors.lastname: Conter
authors.forename: Andrea
authors.initials: A
authors.lastname: Biondi
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Masera
mesh_terms: D000293:Adolescent; D000671:Amputation, Surgical; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D003906:Developing Countries; D019468:Disease Management; D005240:Feasibility Studies; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007391:International Cooperation; D007843:Latin America / Q000453:epidemiology; D008297:Male; D009369:Neoplasms / Q000188:drug therapy / Q000453:epidemiology / Q000628:therapy*; D010352:Patient Dropouts; D011203:Poverty; D012924:Social Conditions; D016896:Treatment Outcome