Vigicáncer: Sistema de monitoreo de resultados clínicos de cáncer infantil
La medición de los resultados clínicos de los niños con cáncer para guiar el mejoramiento de la atención y dirigir intervenciones efectivas tanto institucionales como en políticas en salud.
Oscar Ramírez
A nombre del grupo de trabajo VIGICÁNCER
Oscar Ramírez W.
A nombre del grupo de trabajo VIGICÁNCER
Ángel Castro Dáger Oncohematólogo pediatra, Clinica Blas de Lezo, Universidad de Cartagena
O. Ramirez, V. Piedrahita, P. Aristizabal, L.E. Bravo a nombre del grupo de trabajo VIGICÁNCER
El virus emergente SARS-Cov-2 y su correspondiente enfermedad (COVID-19) ha planteado una seria amenaza a los sistemas de salud de forma global.
Oscar Ramirez,MD,1,2, Paula Aristizabal, MD, MAS3, Vivian Piedrahita, RN1, Francois Desbrandes4, Luis E. Bravo, MD5.
We show that the pediatric cancer overall survival gap by health insurance type in Colombia is a widespread phenomenon despite city size and region.
O. Ramirez P. Aristizabal, V. Piedrahita, F. Ortiz, C. Narvaez, F. Desbrandes, L.E. Bravo
Data on overall survival (OS) for central nervous system (CNS) tumors in children in low-and-middle income countries is scarce.
Epidemiology of childhood cancer in Cali, Colombia 2000-2020.
Cancer mortality in Colombia has decreased around 57% in the last four decades but remains as the second cause of death on children and adolescents from 2-19 years, and the third cause in the group among 1-14 years.
Atun R, Bhakta R, Denburg A et al. Sustainable care for children with cancer: a Lancet Oncology Commission. Lancet Oncol 2020; 21: e185–224. www.thelancet.com/oncology Vol 21 April 2020.
We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020–50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.
Piedrahita R, Bravo LE, Aristizábal MP, Ramírez O. Impacto de la Traslado del traslado interinstitucional en la sobrevida de los niños con Leucemia Linfoide Aguda de Cali 2009-2014. Congreso de la ACHOP Marzo 2019.
El cáncer infantil es un fenómeno creciente que representa entre el 1 y el 2% de todos los diagnósticos de cáncer en el mundo. Más de 250.000 niños padecerán cáncer en este milenio y casi el 90% de estos viven en países en desarrollo. En este momento, para Colombia este grupo de enfermedades son la segunda causa de muerte en niños entre los 2 a 19 años de edad…
Rendón D, Ramírez O, Ardila J, Ortiz F, Narváez C, Portilla CA, Quintero M, Lotero V, Urcuqui LA, Castro MX, Rodríguez P, Barragán L, Araujo L, Medina D. Sobrevida De Niños Con Tumor De Wilms En Cali. Congreso de la ACHOP Marzo 2019.
O. Ramírez, P. Aristizabal, A. Gagnepain-Lacheteau, L.E.Bravo, On Behalf of VIGICÁNCER Working Group. Expansion of a Childhood Cancer Clinical Outcomes Surveillance System in Colombia: Challenges and Opportunities.
Background/Objectives: Assessing childhood cancer clinical outcomes and its determinants is essential for designing effective strategies to improve survival. In 2009, we established a childhood cancer clinical outcomes surveillance system (VIGICÁNCER) in Cali, Colombia. Since geographical location and local settings may affect outcomes, we expanded VIGICÁNCER to other Colombian regions to understand local differences. We describe the challenges and opportunities during expansion.
Design/Methods: We implemented VIGICÁNCER in Cali from 2009-2012 and, in 2013, we expanded it to 8 cities, supported by Cali’s Population-Based Cancer Registry and pediatric oncologists (PO) locally. Our expansion was multi-step and based on standardized operational procedures but allowed flexible adaptations to local needs across regions. Our model includes: a PO leader in each pediatric oncology unit (POU), clinical monitors (CM) collecting data, centralized iterative quality controls and database management/reporting tailored to each region. We established a non-governmental organization (NGO) for management and financial sustainability.
Results: During 2013-2018, we expanded VIGICÁNCER to an area covering ∼50% of Colombian children. As of December 2018, 4127 children were registered. A shared vision of the project’s impact; collective trust among all stakeholders; and enhanced communication by a dedicated, reliable local leader were pivotal to a successful regional implementation.
Key activities/ opportunities to expansion success included: engaged POs; a committed scientific team; effective project management by the NGO; and external mentoring and funding. Capacity building was essential as POUs had no previous outcomes research experience. Local leaders were empowered to build each team. POs and CMs received systematic orientation and ongoing intensive training. To ensure process fidelity at all sites, a CM leader oversees all CMs, and regular, centralized database quality controls were performed.
Conclusions: Our multistep model was successful in establishing and scaling a clinical outcomes pediatric cancer surveillance system in a middle income country, which will inform cancer control efforts.
Ramirez O, Aristizabal P, Zaidi A, Gagnepain-Lacheteau A, Ribeiro RC, Bravo LE; VIGICANCER Working Group. Childhood cancer survival disparities in a universalized health system in Cali, Colombia. Pediatric Hematology Oncology Journal. 2018; 3: 79-87.
Universal healthcare has been proposed as a strategy to achieve health equity. Herein, we describe childhood cancer survival disparities within a universal healthcare system in Cali, the third largest city in Colombia. We prospectively included data from Cali’s childhood cancer surveillance system (VIGICANCER) cohort (2009e2016) and adjusted the hazard ratios (aHR) for confounders using multivariate Cox regression. We included 1808 patients with a median age for children (n = 1499) of 6 years and for adolescents (n = 309) of 17 years. Fifty-six percent were male, 14% were afro-descendants, 61% resided outside of Cali, 52% had public insurance, 44% had private insurance, and 4% were uninsured. Five-year overall survival rates for patients with private insurance, public insurance and uninsured patients were 62% (95% CI: 58, 66), 43% (95% CI: 39, 46) and 23% (95% CI: 13, 35), respectively. Compared to private insurance, mortality among patients with public insurance (aHR = 1.6; 95% CI: 1.3, 1.9) and uninsured (aHR = 2.7; 95% CI: 1.9, 4.0) was higher. We found significant disparate survival outcomes, primarily by insurance and tumor type. Higher treatment abandonment, higher treatment-related mortality, and advanced disease at diagnosis partially explained these disparities. Survival inequalities persist in Colombia despite an established universal healthcare system aimed at providing equal care for all.
Ramirez O, Aristizabal P, Zaidi A, Ribeiro RC, Bravo LE; VIGICÁNCER Working Group. Implementing a Childhood Cancer Outcomes Surveillance System Within a Population-Based Cancer Registry. J Glob Oncol. 2018 Sep;4:1-11. doi: 10.1200/JGO.17.00193.
Purpose: Approximately 80% of cases of childhood cancer occur in low- and middle-income countries and are associated with high mortality rates. Assessing outcomes is essential for designing effective strategies to improve outcomes equally worldwide. We implemented a real-time surveillance system, VIGICÁNCER, embedded in a population-based cancer registry (PBCR) to assess childhood cancer outcomes.
Methods: VIGICÁNCER was established in 2009 as an integral part of Cali’s PBCR to collect realtime data on outcomes of patients (age < 19 years) with a new diagnosis of cancer treated in pediatric oncology units in Cali, Colombia. Baseline and follow-up data (death, relapse, treatment abandonment, second neoplasms) were collected from medical records, hospital discharge logs, pathology reports, death certificates, and the National Public Health Insurance database. A quality assurance process was implemented for the system.
Results: From 2009 to 2013, data from 1,242 patients were included in VIGICÁNCER: 32% of patients were younger than 5 years, 55% were male, and 15% were Afro-descendants. International Classification of Childhood Cancer group I diagnoses predominated in all age groups except children younger than 1 year old, in whom CNS tumors predominated. Five-year overall survival for all cancers was 51.7% (95% CI, 47.9% to 55.4%) for children (< 15 years), and 39.4% (95% CI, 29.8% to 50.5%) for adolescents (15 to 18.9 years). Five-year overall survival for acute lymphoblastic leukemia was 55.6% (95% CI, 48.5% to 62.2%).
Conclusion: Our study demonstrates the feasibility of implementing a real-time childhood cancer outcomes surveillance system embedded in a PBCR that can guide interventions to improve clinical outcomes in low- and middle-income countries.
García LS, Bravo LE, Collazos P, Ramírez O, Carrascal E, Nuñez M, Portilla N, and Millan E. Cali cancer registry methods. Colomb Med (Cali). 2018; 49: 109–120.
Purpose: Approximately 80% of cases of childhood cancer occur in low- and middle-income countries and are associated with high mortality rates. Assessing outcomes is essential for designing effective strategies to improve outcomes equally worldwide. We implemented a real-time surveillance system, VIGICÁNCER, embedded in a population-based cancer registry (PBCR) to assess childhood cancer outcomes.
Methods: VIGICÁNCER was established in 2009 as an integral part of Cali’s PBCR to collect realtime data on outcomes of patients (age < 19 years) with a new diagnosis of cancer treated in pediatric oncology units in Cali, Colombia. Baseline and follow-up data (death, relapse, treatment abandonment, second neoplasms) were collected from medical records, hospital discharge logs, pathology reports, death certificates, and the National Public Health Insurance database. A quality assurance process was implemented for the system.
Results: From 2009 to 2013, data from 1,242 patients were included in VIGICÁNCER: 32% of patients were younger than 5 years, 55% were male, and 15% were Afro-descendants. International Classification of Childhood Cancer group I diagnoses predominated in all age groups except children younger than 1 year old, in whom CNS tumors predominated. Five-year overall survival for all cancers was 51.7% (95% CI, 47.9% to 55.4%) for children (< 15 years), and 39.4% (95% CI, 29.8% to 50.5%) for adolescents (15 to 18.9 years). Five-year overall survival for acute lymphoblastic leukemia was 55.6% (95% CI, 48.5% to 62.2%).
Conclusion: Our study demonstrates the feasibility of implementing a real-time childhood cancer outcomes surveillance system embedded in a PBCR that can guide interventions to improve clinical outcomes in low- and middle-income countries.
Bravo LE, García LS, Collazos P, Carrascal E, Ramírez O, Collazos T, Cortés A, Nuñez M, Millan E. Reliable information for cancer control in Cali, Colombia. Colomb Med (Cali). 2018 Mar 30;49(1):23- 34. doi: 10.25100/cm.v49i1.3689.
Antecedentes: El Registro Poblacional de Cáncer de Cali (RPCC) está en operación continua desde 1962 con el objetivo de producir estadísticas válidas sobre la incidencia de cáncer, sus patrones, tendencias y supervivencia.
Métodos: Durante el periodo 2008-2012, se registraron 23,046 casos nuevos y durante 2011-2015 se registraron 12,761 defunciones por cáncer. La tendencia de las tasas se describió con el porcentaje de cambio medio anual APC y con el análisis de Joinpoint. Se analizaron los datos individuales de 38,671 adultos (15-99 años) con diagnóstico de cáncer entre 1995-2009, y se calculó la supervivencia neta estandarizada por edad para las 14 localizaciones más comunes de cáncer, con el método de Pohar-Perme.
Resultados: Próstata y mama fueron la primera causa de morbilidad por cáncer. Las tasas de incidencia en estos tumores susceptibles de detección temprana se estabilizaron tras décadas de crecimiento, mientras que se observó un incremento de la incidencia de cáncer de colon y carcinoma papilar de tiroides. Las tasas de incidencia de cáncer de cuello uterino y estómago, afecciones relacionados con agentes infecciosos, disminuyeron, aunque el número de los casos absolutos aumentó, debido al crecimiento y envejecimiento de la población. El cáncer gástrico fue responsable del mayor número de muertes por cáncer. Los tipos de cáncer relacionados con el consumo de tabaco (pulmón, cavidad oral, esófago, páncreas, vejiga urinaria) mostraron cifras bajas y con tendencia al descenso. Durante el periodo 2000-2004, la supervivencia neta a 5 años mejoró para los cánceres de mama, cuello uterino, próstata, melanoma y tiroides, aunque en el periodo 2005-2009 se observó un estancamiento. En cáncer de estómago, hígado y pulmón, la supervivencia neta a 5 años fue inferior al 15%. La supervivencia global a 5 años en niños fue de 51.0% (IC 95%: 47.5, 54.3) y en adolescentes de 44.6% (IC 95%: 36.0, 52.8).
Comentario: RPCC ha sido asesor del gobierno colombiano en la evaluación de RPCs en el país y sus datos han contribuido significativamente a diferentes aspectos del control del cáncer en Colombia.
Urcuqui LA, Castro MX, Medina D, Aristizabal P, Bravo LE., Ramírez O. Neuroblastoma survival in a middle income country: A report of VIGICÁNCER Pediatric Cancer Surveillance System From Cali, Colombia.
Background/Objectives: In high-income countries, neuroblastoma (NB) is the most common extracranial solid tumor with a 70% 5-year survival. In Cali, the third largest city in Colombia, the annual incidence of NB is 3.8 per million children, being the 6th most common extracranial solid tumor. Outcome data in low and middle-income countries are scarce. We describe the survival of children with NB in Cali.
Design/Methods: VIGICÁNCER was established in 2009 – with the support of Sanofi-Espoir Foundation’s “My Child matters program” -within Cali’s cancer registry to collect data on outcomes of patients <19 years old with a new diagnosis of cancer treated at pediatric oncology units. Baseline and follow-up data were collected from medical records, hospital discharge logs, pathology reports, death certificates, and the National Public Health Insurance database. Survival analyses were performed using Kaplan-Meier.
Results: From 2009-2017, we identified 52 NB within 1711 children (<15 years of age) registered. Median age was 1.8 years (range: 0.02 to 12), 44% male, 21% afro-descendants, 21% stage 3, 68% stage 4, 76% high-risk, and 27% achieved complete response. 47% of high-risk patients underwent autologous BMT. Treatment-related deaths and abandonment were 18% and 10%, respectively. Five-year overall survival (OS5y) and event-free survival (EFS5y) was 37% (95%CI:22, 52) and 30% (95%CI: 16, 46), respectively. In patients <1 year of age, EFS5y was 61% (95%CI: 29, 82). EFS5y for stage 3 and 4 was 42% (95%CI: 7, 75) and 21% (95%CI: 7, 42%), respectively. All stage 1 and 2 patients are alive. For stage 4 patients, EFS5y was higher in patients with semiprivate insurance
compared to those with public health insurance (42% vs. 9%;P=0.06).
Conclusions: NB survival in Cali is 30% lower than in highincome countries. We found a survival disparity between health insurance types. High treatment-related death, abandonment and limited access to autologous stem-cell transplant contribute to this survival gap.
Castro MX, Bravo LE, Aristizabal P, Ramírez O. High frequency of metastatic Osteosarcoma/Ewing sarcoma at diagnosis do not explain their poor survival in Cali, Colombia: A report of VIGICÁNCER Pediatric Cancer Surveillance System. DOI:10.1002/pbc.27989.
Background/Objectives: In low and middle-income countries (LMIC), Osteosarcoma and Ewing sarcoma (O&E) survival is dismal. High frequency of advanced disease at diagnosis is a major contributing factor on poor survival in LMIC. However, literature is scarce on all contributing factors in LMIC. Herein we describe outcomes of children with metastatic and non-metastatic O&E in Cali, Colombia.
Design/Methods: VIGICÁNCER was established in 2009 – with the support of Sanofi-Espoir Foundation’s “My Child matters program” – within Cali’s cancer registry to collect data on outcomes of patients <19 years old with a new diagnosis of cancer treated at pediatric oncology units. Baseline and follow-up data were collected from medical records, hospital discharge logs, pathology reports, death certificates, and the National Public Health Insurance database. Survival analyses were performed using Kaplan-Meier. We included only O&E for analyses. Kaplan-Meier method was used for survival analyses and Cox regression for adjusted hazards rates (HRa).
Results: From 2009 to 2017, we identified 101 Osteosarcomas and 46 Ewing from 2115 patients. Mean age was 13.1 (SD: 3.6) years old. 55% were males, 7% were afrodescendants, and 55% had public insurance (PI). Metastatic O&E (mO&E) was 69% in the PI patients compared to 34% in the semi-private insurance(SPI); P=0.001. Osteosarcoma and Ewing 5-year overall survival (OS5y) was 25%(95%CI:14, 38) and 36%(95%CI:19, 53), respectively. OS5y for mO&E was 9% (95%CI:2,24), compared with 32%(95%CI:15, 60) for non-mO&E. Treatment related mortality and abandonment was 3% and 5%, respectively. mO&E was not associated with increased mortality (HRa=0.97 (95%CI:0.89, 1.08). PI HRa was of 2.81(95%CI: 1.54, 5.1) and Afro-descendants 3.06 (95%CI:1.24, 7.53).
Conclusions: We found that the role of disease extension as a prognostic factor was inconsistent in our patient population, similar to data from the pre-chemoterapy era. More research is needed to identify all contributing factors to dismal outcomes in LMIC to implement more effective treatments.
Ramirez O. Information and Childhood Cancer. Colomb Med (Cali). 2016 Jun 30;47(2):74-5.
El cáncer representa la tercera causa de mortalidad en el grupo de 1 a 14 años de edad en Colombia. Aunque el cáncer de la niñez (<15 años) constituye una pequeña proporción (0.5-3%) de toda la carga de enfermedad atribuida al cáncer en la población, la mayor parte (84%) de estos cánceres ocurren en países de medianos y bajos recursos, donde se encuentra el 90% de la población
infantil. El Registro Poblacional de Cáncer de Cali (RPCC) ha documentado un aumento de 0.9% en la variación porcentual anual de la incidencia global medida desde 1977 al 20111.
Ospina-Romero M, Portilla CA, Bravo LE, Ramírez O; VIGICANCER working group. Caregivers’ Self-Reported Absence of Social Support Networks is Related to Treatment Abandonment in Children with Cancer. Pediatr Blood Cancer. 2016;63:825-31. doi: 10.1002/pbc.25919.
Background. Treatment abandonment (TxA) is a primary cause of therapy failure in children with cancer in low-/middle-income countries.We explored the absence of social support network (SSN), among other predictive factors, and TxA in children with cancer in Cali, Colombia.
Procedure. In this prospective cohort study, we included children diagnosed with cancer at a public university hospital. A social worker and a psychologist administered semistructured questionnaires to patients’ caregivers.We extracted information from the questionnaires about social, economic, and psychological conditions of the patients’ families. Outcomes were death, relapse, and TxA. Failure either to start or to continue the planned course of curative treatment for 4 weeks or more was defined as TxA.We identified events with Cali’s childhood cancer outcomes surveillance system (VIGICÁNCER). We adjusted the hazard ratios (HRs) for potential confounders using multivariate Cox regression analyses.
Results. Among 188 patients diagnosed from January 2011 to June 2013, 99 interviews were conducted. Median age was 5 years old (range: 0.3, 14.9), 53% were male, 17% were of Colombian-Indian ethnicity, and 68% lived in rural areas. The 2-year cumulative incidence of TxA was 21% (95% confidence interval [CI]: 13, 35) and the annual proportion was 14%. The adjusted HR for the absence of SSN was 4.9 (95% CI: 1.6, 15.3).
Conclusions. We found a strong association between the absence of SSN and TxA that was independent of other covariates, including surrogate measures of wealth. Our findings highlight the imperative understanding of social ties and support surrounding children’s families for planning strategies to prevent TxA.
Gupta S, Aitken JF, Bartels U, Brierley J, Dolendo M, Friedrich P, Fuentes-Alabi S, Garrido CP, Gatta G, Gospodarowicz M, Gross T1, Howard SC, Molyneux E, Moreno F, Pole JD, Pritchard-Jones K, Ramirez O, Ries LAG, Rodriguez-Galindo C, Shin HY, Steliarova-Foucher E, Sung L, Supriyadi E, Swaminathan R, Torode J, Vora T, Kutluk T, Frazier AL. Paediatric cancer stage in population-based cancer registries: the Toronto consensus principles and guidelines. Lancet Oncol. 2016;17:e163-e172.doi: 10.1016/S1470-2045(15)00539-2.
Population-based cancer registries generate estimates of incidence and survival that are essential for cancer surveillance, research, and control strategies. Although data on cancer stage allow meaningful assessments of changes in cancer incidence and outcomes, stage is not recorded by most population-based cancer registries. The main method of staging adult cancers is the TNM classification. The criteria for staging paediatric cancers, however, vary by diagnosis, have evolved over time, and sometimes vary by cooperative trial group. Consistency in the collection of staging data has therefore been challenging for population-based cancer registries. We assembled key experts and stakeholders (oncologists, cancer registrars, epidemiologists) and used a modified Delphi approach to establish principles for paediatric cancer stage collection. In this Review, we make recommendations on which staging systems should be adopted by population-based cancer registries for the major childhood cancers, including adaptations for low-income countries. Wide adoption of these guidelines in registries will ease international comparative incidence and outcome studies.
Bravo LE, Garcia L, Collazos P, Ramírez O. Descriptive epidemiology of childhood cancer in Cali, Colombia 1977-2011. Colombia Medica 2013;44:155-164.
Aim: The objective of the present report is to describe the occurrence and survival patterns of childhood cancer over the last 20 years in Cali.
Methods: Information was obtained from the Cancer Population Registry in Cali and the Municipal Department of Health . Childhood cancer international classification was used. The vital status was obtained from MDH death certificate and hospital databases. Additionally, clinical records were revised and, in some cases, telephone contact was carried out. Follow-up was done until 31/12/2011. Incident and mortality rates were estimated and adjusted for age. Life-tables were made to estimate overall survival.
Results: Between the years of 1977-2011, there were 2311 cases identified in children under 15 years of age. The IR and MR for Cali were found to be 141.2 and 55.6 per million of people per year. Leukemias, lymphomas, CNS tumors and soft tissue sarcomas showed IR of 60.1, 20.5, 25.7 and 9.4, respectively. 5-years OS was 48%, and showed an improvement from 24.9%±4.3 to 51.8%±4.6, compared 1992-96 vs 2002-06 periods.
Conclusion: The IR found is comparable with those described in affluent countries. Taking into account that pediatric cancer is curable for about 75-80% of the cases, it presents an enormous challenge to the Colombian health system: to improve current clinical results.
Ramirez O, Aristizabal P, Zaidi A, Ribeiro RC, Bravo LE; VIGICÁNCER Working Group. Implementing a Childhood Cancer Outcomes Surveillance System Within a Population-Based Cancer Registry. J Glob Oncol. 2018 Sep;4:1-11. doi: 10.1200/JGO.17.00193.
Purpose: Approximately 80% of cases of childhood cancer occur in low- and middle-income countries and are associated with high mortality rates. Assessing outcomes is essential for designing effective strategies to improve outcomes equally worldwide. We implemented a real-time surveillance system, VIGICÁNCER, embedded in a population-based cancer registry (PBCR) to assess childhood cancer outcomes.
Methods: VIGICÁNCER was established in 2009 as an integral part of Cali’s PBCR to collect realtime data on outcomes of patients (age < 19 years) with a new diagnosis of cancer treated in pediatric oncology units in Cali, Colombia. Baseline and follow-up data (death, relapse, treatment abandonment, second neoplasms) were collected from medical records, hospital discharge logs, pathology reports, death certificates, and the National Public Health Insurance database. A quality assurance process was implemented for the system.
Results: From 2009 to 2013, data from 1,242 patients were included in VIGICÁNCER: 32% of patients were younger than 5 years, 55% were male, and 15% were Afro-descendants. International Classification of Childhood Cancer group I diagnoses predominated in all age groups except children younger than 1 year old, in whom CNS tumors predominated. Five-year overall survival for all cancers was 51.7% (95% CI, 47.9% to 55.4%) for children (< 15 years), and 39.4% (95% CI, 29.8% to 50.5%) for adolescents (15 to 18.9 years). Five-year overall survival for acute lymphoblastic leukemia was 55.6% (95% CI, 48.5% to 62.2%).
Conclusion: Our study demonstrates the feasibility of implementing a real-time childhood cancer outcomes surveillance system embedded in a PBCR that can guide interventions to improve clinical outcomes in low- and middle-income countries.
Abandonment Hazard Is Dependent on Time, Age And Tumor Type In Children With Cancer: A Report Of Vigicáncer Pediatric Cancer Surveillance System From Cali, Colombia. Ramírez O, Aristizabal P, Bravo LE, en nombre del grupo de trabajo de VIGICÁNCER. Presentado en el Congreso de la Sociedad Internacional de Oncología Pediátrica, Hong Kong, Septiembre 2013. Pediatric Blood and Cancer 2013; S1-S2634.
Purpose/Objective: Treatment abandonment is a key determinant of cure in children with cancer in developing countries. We describe the variations of abandonment hazard related to time, and other variables in children with cancer in Cali, the third largest city in Colombia.
Materials and Methods: VIGICÁNCER-Childhood Cancer Outcomes Surveillance System – was established in Cali in 2009. We prospectively enrolled children with a new diagnosis of cancer and collected data from January 2009 to December 2012. Data sources included medical records, pathology reports, direct patient observation, parental interviews and death certificates. Outcomes measured in real-time included cancer relapse, death, secondary tumors and treatment abandonment. Active follow-up was done every 3 months. Instantaneous hazard of abandonment was estimated by time and stratified into different variables. Independent predictors of abandonment were calculated with multivariate Cox’s regression analyses.
Results: There were 802 children (<15 years) included in the analysis and 758 (94.5%) were actively followed-up. Thirty-six month overall survival was 57% (95%CI:52, 62). Globally, 8% (95%CI: 6, 10) of patients abandoned treatment. Abandonment was higher in patients with governmental insurance when compared to private insurance (16% vs 2%), with a hazard ratio of 9.7 (95%CI: 4, 22). Hazards curve for abandonment showed the highest peak (4.2%) at 18-20 weeks from diagnosis in children <10 years with Acute Lymphoblastic Leukemia. Patients with age 10-15 years with Acute Myeloid Leukemia showed a steady increasingly hazard with a maximum of 1.5%occurring 70-80 weeks. Other types of cancer showed a peak (2.6%) at 15-29 weeks. Conclusions: Our findings suggest that interventions aiming to decrease abandonment should be carefully planned to take into consideration patient age, time since diagnosis and tumor type, in addition to other complex social issues. Tailored interventions are urgently needed to be further investigated and implemented.
Initial results of Vigicáncer pediatric cancer outcomes surveillance system established in Cali, Colombia. Ramírez O, Aristizabal P, Bravo LE, en nombre del grupo de trabajo de VIGICANCER. Presentado en el Congreso Mundial de Cáncer, Montreal August 2012.
Background: In 1993, Colombia moved from a centralized government-based health care system to a new model, based in private, semi-private and government health insurance companies under the principles of universality, social solidarity and participation. In a report of Cali´s Cancer Population-based Registry (1994-2003), 3 year childhood cancer overall survival (OS) was 53% (95%CI: 49, 57) and childhood acute leukemia OS was 47% (95%CI 41, 53). Based on these findings, we established in 2009, VIGICÁNCER-Childhood Cancer Outcomes Surveillance System, with the support of UICC-Sanofi/Espoir “My Child Matters” program. It is the first pediatric cancer surveillance system in the country and, to our knowledge, one of the few in Latin America.
Objectives: we aimed to create a real-time surveillance of childhood survival, to describe survival determinants, and to communicate our findings to public health autrhorities.
Methods: children with a new cancer diagnosis and treated in a pediatric oncology facility in Cali, the third largest city in the country, were prospectively enrolled. Medical records, pathology reports, direct patient observation, parents interviews and death certificates, were used as information sources. Outcome events were registered in real-time and included: relapse, treatment abandonment and death. Active follow-up was done every 3 months. Survial analyses werw performed using Kaplan-Meier. Data from the past 3 years analyzed and estimates were adjusted using Cox´s regression.
Results: Between 01/2009-01/2012, 619 children (<15 yrs) with cancer were diagnosed and 577 (93%) were followed up. Median age was 6 years, 54.9% were males and 17.6% were afrodescendants. The most frequent tumors were acute leukemias (40.3%), CNS tumors (14.1%), lymphomas (12.9%), bone tumors (5.5%), Wilms tumors (5.0%), retinoblastoma (4.7%), soft tissue sarcomas (4.5%), and neuroblastoma (3.1%). Thirty-three month OS was 51% (95%CI: 44, 59). Acute leukemia (AL) 33 months-OS was 61% (95%CI: 51, 70). OS for patients with private insurance was 68% (95%CI: 58, 76) and 45% (95%CI: 33, 56) for patients with government and semi-private insurance (P value=0.02). Hazard Ratio was 1.50 (95%CI: 1.1, 2.2). This difference was independent of their covariates such as age, gender, tumor type and race.
Conclusion: Childhood cancer OS has not improved in the last 10 years in Cali. Nevertheless OS for AL seems to be encourangingly improving. We found disparities in OS among different insurances schemes, despite an alleged equal access to care for all. As our system involves patients from different regions of Colombia, the tumor distribution is affected by referral patterns explaining the high frequency of retinoblastoma. Further research is warranted to address especific barriers encountered in the current health care system. This special type of surveillance system has provided critical information that should translate into policies to improve outcomes in children with cancer.