Beryl Thyer
Memorial Africa Trust
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Burkitt's Lymphoma: More info
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A group of Burkitt's Lymphoma cases in Dr Burkitt's care.
Mulago Hospital, Kampala, Uganda, in 1960
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A group of Burkitt's Lymphoma cases in Banso Baptist Hospital,
Kumbo, Cameroon, in 2003
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This is a global disease; sporadic in most of the world (there have been 4 cases in Kettering in the UK in the past 9 years), but endemic and very common in Tropical Africa (7 cases in the month of July 2004 at one of our hospitals in Cameroon, and more than 100 cases at BBH, and 40 cases at MBH in 2005. It is a cancer of children; the most aggressive and malignant cancer known to medical science; the commonest cancer of children in Africa. It is more common than all other childhood cancers in Africa put together. It is a horrific and disfiguring disease. It is invariably fatal in weeks or a few months if not detected and treated. IT IS TREATABLE - and with a good hope of cure. By English standards the treatment is not expensive; for poor Africans it is impossibly expensive. Hospitals cannot afford to stock the necessary medicines, and if they could, the people could not afford to purchase them from hospital pharmacies. One third of the Cameroon population lives on less than $1 per day; this is about 60 pence per day. There is of course no national health service, and only the privileged very few can afford private medical insurance. African boys and girls therefore die because their parents are poor and ignorant.
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Three cases of classical Burkitt's Lymphoma; tumours in the face.
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For me this scenario of children dying in misery of a dreadful malignancy was intolerable. Since 1997 I have been devoting much of my life, thought, fundraising and practical work in Cameroon to lessen this burden. I now have many senior doctors to guide and support me in my efforts. At the two Cameroonian hospitals I support we are offering investigation of suspected Burkitt's cases, treatment of them, hospital costs for them, and follow-up of them - entirely free of charge. We are now part of a pan-African Trial to investigate the most appropriate, effective and affordable treatment for such children. I am the Cameroon co-ordinator of a series of Trials under the auspices of the International Society of Paediatric Oncology (SIOP). Our overall co-ordinator is Professor Peter Hesseling of Stellenbosch University, Western Cape, S Africa. Our results are most encouraging; at least 60% of the cases we treat are in remission - hopeful cures - one year after cessation of their chemotherapy.
The results of the first Trial - which took place concurrently in Malawi, Ghana, and Cameroon - and likely to spread to a further 7 African countries soon - were presented at a SIOP Conference in Vancouver, Canada, in September 2005. Our results will be published. Here is the abstract for our Poster presentation; it is somewhat technical, so if you are not a medic, and don't want the details, then skip it:
High Frequency Intravenous Cyclophosphamide with Intrathecal Methotrexate in Endemic Burkitt's Lymphoma, at Banso Baptist Hospital, NW Province, Cameroon.
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Peter, on the right, presents the results of our Trial at the annual conference of the International Society of Paediatric Oncologists, Vancouver, Canada, September 2005
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Dr Peter A McCormick, Dr F Tchintseme,
Banso Baptist Hospital,
Paediatrics,
Kumbo,
Nso,
NW Province,
Cameroon
Professor P B Hesseling,
Stellenbosch University,
Paediatrics,
Tygerberg,
S Africa
Introduction: A high prevalence of Burkitt's Lymphoma (BL) and limited resources, made this Protocol an interesting treatment option.
Patients and methods: All children admitted 01/03/03 to 28/2/04 with clinically suspected BL were subjected to fine needle aspirate (FNA), bone marrow biopsy and lumbar puncture, for cytology. Abdominal ultrasound and baseline investigations were done in all cases. St Jude staging was used. Children with stage I and II disease received cyclophosphamide 40mg/kg IV and methotrexate 15mg plus hydrocortisone 15mg IT, on days 1, 8, and 15. In stage III and IV cyclophosphamide was added on days 29, 43, and 57. We recorded the response to treatment on day 21, and event-free survival (EFS) at one year. Patients who died during treatment, absconded or were lost to follow-up are included in the Kaplan Meier analysis.
Results: 34 children (17 male, 17 female) median age 7 years, range 3 to 15 years, with St Jude stage I: 0; II: 3; III: 25; IV: 6, were enrolled. A complete clinical response was achieved by day 21 in 26 (77%) of patients. Two deaths occurred during treatment and 6 had resistant disease. Projected EFS at one year is 66% for stage II, 62% for stage III, and 16% for stage IV disease.
Conclusion: High frequency cyclophosphamide plus intrathecal methotrexate achieved a >60% projected EFS in children with stage II and III BL
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After this Trial ended (last registered case to be admitted was at the end of Feb 2004) we initiated another Trial, using information and experience from the first one. In addition to this, we are about to launch a Rescue Protocol, designed for children already in our latest treatment protocol, but who have relapsed or proven resistant to treatment. This Trial must run for one year, and the children in it must be followed up for a further year. We know that if a child with BL is free of the disease one year after cessation of treatment, he or she is very unlikely to relapse. We are thus justified in speaking of 'cures'.
But even after our clinical trials are over, we must continue to treat children. There is - and will continue to be - an ongoing search for funds for this.
A summary of the clinical small (pilot) trials which we have conducted in Cameroon, based on, and identical to trials in Malawi, is as follows:
Year
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Name of Trial
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Date of Trial
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Follow-up time
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2003
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Malawi 2002
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1/03/03 - 28/02/04
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1/03/04 - 28/02/05 *
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2004
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Malawi 2003
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1/03/04 - 28/02/05
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1/03/04 - 28/02/05 *
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2005
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Malawi 2005
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1/11/05 - 31/10/06
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1/11/06 - 31/10/06 ***
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* This Trial used intravenous cyclophosphamide throughout. The trial has completed its one year follow-up. Its statistics are shown above, have been presented in Vancouver and London, and will be published in Pediatric Blood and Cancer - the journal of the International Society of Paediatric Oncology (SIOP).
** This Trial used intravenous cyclophosphamide for the first treatment, and oral cyclophosphamide for all subsequent treatments. This Trial has been completed at BBH, but the follow-up period is continuing. The results from this trial will be presented in the SIOP Annual Conference in Geneva, Switzerland, in September 2006. MBH has partaken in this Trial. Their cases will be presented in Marrakesch, Morocco, in March 2006, at a SIOP Conference designed for Paediatric Oncology in Developing Countries.
*** The Malawi 2003 Trial being now completed, the treatment of BL children continues using that Protocol, but without the previously necessary investigations required for a scientific trial. The new addendum protocol available to the children now admitted, is designed for those children who relapse, or whose disease appears to be resistant to the 2003 Protocol. It will be 2007 before we can analyse our results of this additional Rescue Protocol.
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Various sources have been generous to date. Baxter Oncology GmbH in particular - the manufacturers of Cyclophosphamide (Endoxan) - the main anti-cancer drug - continue to support our cause. Early this year the Company accepted the Trust into a product donation agreement. This partnership will remove anxiety regarding the supply of their product to our BL children.
Other necessary drugs of course will become exhausted, but the work must go on. Can it ever become sustainable? A question to which I do not know the answer. We continue to broadcast our work to the Country; a Cameroonian TV video has been made featuring the full history of one of our cases; three national radio programmes have gone on air and more are planned; local chiefs and their servants have been approached and are spreading news of our service to remote bush villages. All we can do at our hospitals, is to continue to investigate and treat for as long as funds last.
We have a plan to involve the few rich and successful businessmen of Cameroon in the funding of our work. One such has recently opened a premises in Kumbo town - only one mile from the hospital.
We hope that the Cameroonian government Ministry of Health will in due course see and appreciate the work being done for their children, and apply political pressure for subsidisation of the costs of the medicines for Burkitt's lymphoma - in much the same way as for TB and AIDS medicines in Africa. We must hope that the WHO, the World Bank, UN and UNICEF - will recognise the medicines for BL should be classified as essential, and will subsidise the cost of the drugs in those poor African countries worst affected by the disease. In this context it is heartening to know that movement at high level is taking place; four recent references highlight this fact:
the La Mascota programme from Nicaragua, 1998, was based on the belief that an attempt to reduce the gap in mortality from cancer in childhood between developed and less developed countries should become an integral part of the care and research activity of cancer centres in the developed world. The feasibility and funding of twinning between developed and developing world child cancer units is discussed, using their own experience in Nicaragua. 'Failure to treat life-threatening diseases represents a violation of the fundamental rights of children, and of the professional duties of the health-care community'. G Masera, F Baez and others, Lancet 1998; 352: 1923-1926
the Ponte di Legno Group statement, 2004 re-iterates the sentiments of the La Mascota programme, and though considering chiefly childhood leukaemia, states that its recommendations should extend to all childhood cancers.'[We] herewith emphasize the right of all children in the world to full access to the essential treatment of acute lymphatic leukaemia and other cancers, and call upon all authorities concerned, to recognize and support all measures that can promote this right to a chance of cure'. G Masera, T Eden and others. Pediatric Blood and Cancer, 2004; 43: 103-104
Eva Steliarova-Foucher 2004, wrote an article stating the same things, and points out the importance of well-kept child cancer registries. She reminds us again that world-wide, most children with cancer live in developing countries., that twinning of low-income with resource-rich countries is needed, and that 'the challenge before us is to ensure equity of access to cancer care for all children'.Eva Steliarova-Foucher and others, Lancet 2004; 364: 2074-2076.
Barr and colleagues advance a step further by proposing a formulary of essential drugs for childhood cancer in developing countries. The scene is set for further necessary advances. The professionals have the knowledge, experience, the passion and the voice. What is needed is political will and action. R Barr, A Sala, G Moto and others; A formulary for pediatric oncology in developing countries. Pediatric Blood Cancer, 2005; 44: 433-435
I will close this page with a quotation by Professor Tim Eden - the first professor of childhood and adolescent cancer in the world - at Manchester University, UK. He writes in the news bulletin of UICC - International Union against Cancer, in December 2005; 'Nowhere in the world is the disparity between north [the developed countries] and south [the developing countries] more clearly evident than in the treatment of childhood cancer. Nowadays most children with cancer are curable [in the developed countries]; this is not the case with endemic BL and other childhood malignancies in the developing world, where the majority of children with cancer are still dying. 80% of all children with cancer live in the developing world'.
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Thought for the day:
De Gud Nyus weh
MATTHEW
bin rait-am
18:
1. Fo daa tam Jesus yi lanboi dem kam ask yi sei, “Na hu go big man pas oda pipul fo king fo heven yi rul ?”
2. Jesus e kol som smol pikin an e put yi fo dem bifo
3. an e tok fo dem sei, “A tel wuna tru sei, if wuna no cheinj teik wuna sef fo be lek smol pikin, wuna no fit kam enta fo king fo heven yi rul.
4. Eni man weh e teik yi sef lek dis smol pikin e na big man fo king fo heven yi rul.
5. Eni man weh e welkam pikin lek dis wan fo ma neim, e welcam ne mi”
6. “Eni man weh e meik eni smol man fo dis wan weh dem put dem hat fo mi, fo du bad, e fo beta fo yi sei meik dem hang graining stun fo yi nek an dem truwei yi for insaid dip pleis fo si.
Cameroonian Pidgin
The Gospel According to
ST. MATTHEW
18:
1. At the same time came the disciples unto Jesus, saying, Who is the greatest in the kingdom of heaven ?
2. And Jesus called a little child unto him, and set him in the midst of them,
3. And said, Verily I say unto you, Except ye be converted, and become as little children, ye shall not enter into the kingdom of heaven.
4. Whosoever therefore shall humble himself as this little child, the same is greatest in the kingdom of heaven.
5. And whoso shall receive one such little child in my name receiveth me.
6. But whoso shall offend one of these little ones which believe in me, it were better for him that a millstone were hanged about his neck, and that he were drowned in the depth of the sea.
King James
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(Burkitt's: More info)
Beryl Thyer Memorial Africa Trust, a UK registered charity ~ 1112603