Introduction. Childhood cancer is relatively rare, but there is a very good chance of cure. While overall survival rates of >70% are reported from developed countries, survival is much less likely in developing countries and unknown in many countries in Africa.
Objective. To analyse survival rates of childhood cancers in two South African paediatric oncology units.
Methods. This retrospective review included all children (0 - 15 years) admitted with a malignancy at two paediatric oncology units (Universitas Hospital Academic Complex in Bloemfontein, Free State, and Tygerberg Hospital in Cape Town, Western Cape) between 1987 and 2011. The protocols used in the units were similar, and all the diagnoses were confirmed histologically.
Results. There were 3 241 children, 53.5% of whom were males. Median follow-up was 17 months. The most common cancers were leukaemia (25.0%), brain tumours (19.5%), lymphoma (13.0%) and nephroblastoma (10.0%). The prevalences of neuroblastoma and retinoblastoma were similar at 5.8% and 5.7%, respectively. Overall survival was calculated to be 52.1%. Lymphoma and nephroblastoma had the highest survival rates at 63.9% and 62.6%, respectively. Brain tumours had the lowest survival rate at 46.4%. A comparison between ethnic groups showed white children to have the highest survival rate (62.8%); the rate for children of mixed racial origin was 53.8% and that for black children 48.5%.
Conclusions. Overall survival rates for children admitted to two paediatric cancer units in South Africa were lower than data published from developed countries, because many children presented with advanced disease. New strategies to improve cancer awareness are urgently required.
In November 2013, the International Children's Palliative Care Network (ICPCN), based in South Africa, and the United Nations Children's Fund (UNICEF) released a document entitled Assessment of the Need for Palliative Care for Children. Three Country Report: South Africa, Kenya and Zimbabwe. It reported that, even though an underestimate, >800 000 children in South Africa were in need of generalised palliative care and >300 000 in need of specialised palliative care. Moreover, it was estimated that only 5% of children requiring specialised care were being reached. This low coverage was a result of 'inadequate inclusion of children's palliative care within policy and strategy frameworks; widespread lack of knowledge and adequate understanding among health professionals; narrow target focus of services being provided already; the reluctance of health workers to prescribe and/or administer morphine despite the availability of essential palliative care pharmaceutical agents, resulting in a major barrier for access to comprehensive pain management; funding constraints and attendant poor integration of palliative care into the health system'.
When should one withdraw treatment in children? The challenge is to recognise when a decision needs to be made. Parents may be in denial, and deciding which questions to ask may be difficult. Ethically, the guiding principle should be the child's best interests. May the parents or primary caregiver decide what the child's best interests are? Legislation in South Africa prevents a parent or caregiver from refusing treatment that medical professionals deem to be in the child's best interests. This article discusses the ethical and legal aspects around the decision to palliate in children.
Talking to children can be very daunting. Talking to a sick child can be even more daunting. How can we ensure that our message comes across in a way that is suitable and will not cause more harm than good?
George Bernard Shaw stated, 'The single biggest problem in communication is the illusion that it has taken place'. In the medical world, and especially one that involves children, this is unfortunately a reality.
Managing disease- and procedure-related pain in children is paramount. Chronically ill children, especially those requiring repeated procedures or admissions, may experience a significant burden of pain. If poorly managed, it has a negative impact on quality of life and parent-child relationships.
According to the World Health Organization (WHO), the principles of palliative care are applicable to all children with chronic illnesses from the time of diagnosis. A key component of palliative care is good pain management.
Many of us have worked in the interminable queues of outpatient departments. After a long day, we are greeted with the hopeful, tired faces of families with their ill loved ones. We are meant to be able to heal and cure. Yet, we often run out of options, treatments seem ineffective, and we have to hold the hands of those who are dying.
Doctors have mostly been trained to cure. They make significant sacrifices in family life, sleep, personal time and hobbies to be able to pursue this ideal. Moving away from cure to compassionate care of dying patients, is a paradigm shift. This can be particularly difficult when caring for children with terminal illness. It is easier to accept death in the elderly as it is part of the natural order of life. Caring for dying children can, however, be draining on both staff and families.