Partner Profile

Pediatric Hematology Oncology at the National Institute of Pediatrics in Mexico City

by Dr. Roberto Rivera-Luna
Head, Division of Hematology/Oncology

The National Institute of Pediatrics in Mexico City is struggling to reverse escalating cancer mortality among children aged 4 to 15. Cancer is the second leading cause of death among this age group.

Introduction
The Instituto Nacional de Pediatria (INP), or National Institute of Pediatrics, exists within the framework of the National Institutes of Health in Mexico City. It is a tertiary care, university-affiliated (Universidad Nacional Autónoma de México) referral institution dedicated exclusively to pediatric care. Founded in 1970 by presidential decree as a not-for-profit organization supported by the federal government, its sole purpose is the care of sick children.

The physical structure consists of four separate buildings. A four-story hospital includes outpatient clinics, a 260-bed in-patient section in which all pediatric specialties are represented, general and specialty laboratories, an imaging section with CAT scan, X-rays and nuclear medicine, and a radiotherapy (cobalt 60) unit. A second, 10-story building is dedicated exclusively to basic research and includes an animal facility housing 16 animal species. A third building comprises the Residency, with accommodation and a cafeteria sufficient for 214 full-time house staff. The fourth building is an administrative unit. The INP is one of the three tertiary pediatric care hospitals in the Republic of Mexico, and the Pediatric Oncology Division is considered by the Mexican Federal Health Authority to be a national referral center for acute leukemias, brain tumors, retinoblastoma, and bone marrow transplantation. The tertiary care hospitals are dedicated to academic pursuits, research, and patient care, in that order.

Mexico is a developing nation with a population of 98 million inhabitants, of whom 60% are under 18 years old. Until three years ago, cancer was the fifth leading cause of death in children aged from 4 to 15 years. However, federal health officials have reported that since 1998 cancer is second only to accidents as a cause of death in this age group. Currently there are 86 Mexican Board Certified pediatric oncologists all over the nation, 21 of whom are practicing in Mexico City. Among the 31 states of the republic, 12 do not have qualified pediatric oncologists and here, children with cancer are generally diagnosed and treated by adult hematologists or oncologists.

Clinical Service
The Division of Hem/Oncology at the INP is made up of the Departments of Hematology, Oncology and Radiotherapy as well as a Bone Marrow Transplantation Unit. Twelve full- time board-certified physicians work in the three departments. In addition, a full-time psychologist is dedicated exclusively to oncology patients and three social workers. There are 46 beds assigned to the division. Each department has a full-time pediatric head nurse and several nurses per shift. An average of 700 new patients per year are registered in the three departments and 4,800 follow-up patients are seen per year, giving a total of 5,500 patients seen per year. Unfortunately, 25-30% of these patients fail to complete their treatment or are lost to follow-up, mostly due to the fact that 60% of the patients come from rural and semi-rural areas 1,000 kilometers or more away from the INP.

The departments of hematology and oncology have their own laboratories, which include automatic instruments for routine hematology and chemistry. There is also a cryopreservation unit and tissue typing laboratory for bone marrow transplantation.

Residency Program
In its 30 years of existence the INP has trained 38 pediatric oncology fellows, of whom six have been from other Latin American countries. In 1979, a clinical residency program was established. The requirements for enrollment in this program include having a Mexican medical license, approval for the National Residency Board Examination, completion of a three-year university pediatric residency program, and having Mexican Pediatric Board-Eligibility or Certification. Foreigners must have their pediatric certificate validated by the National University of Mexico and must pass the National Residency Board Exam. The residency program in pediatric oncology at our institution, and nationwide, is a two-year program. It includes being on-call every four days. The hospital provides accommodation and meals for all residents. Currently there are three junior and three senior fellows. The first academic year has clinical rotations through the outpatient department, bone marrow transplant unit, in-patient department, ambulatory care, radiotherapy (visiting fellow) and the oncology laboratory. The senior fellows, besides supervising the junior house staff, make daily rounds with the pediatric residents rotating through the Oncology Division, and in addition, are required to undertake clinical and/or basic research. They also participate in all consultations with senior staff members, direct the weekly seminars, journal club and the weekly Joint Tumor Board Conference, have active participation in the development of leukemia, lymphoma and solid tumors protocols, and are required to produce at least one scientific medical paper. They may choose to spend six weeks in any pediatric oncology department/institution in the USA as a visiting fellow.

The Pediatric Hematology Residency Program has similar requirements for national and foreign fellows who undertake the two-year residency. Residents are trained in the care of all benign hematological conditions of childhood as well as the treatment of leukemia. A Visiting Professor Program, established 20 years ago, brings an expert pediatric hematologist or oncologist from an American institution to visit the department of oncology. For three days each year, visiting professors participate actively in ward rounds, see patients in the out-patient department with the fellows, participate in the weekly Tumor Conference, and give a presentation at the Tuesday Formal Hospital Conference. Visiting professors may also discuss in-house treatment protocols and suggest modifications. Occasionally a pediatric hematology/oncology fellow from USA has elected to spend several weeks at the INP.

Research Activities
Research is being conducted in both clinical and basic areas and inter-departmental collaborations include ongoing studies with the departments of genetics, molecular biology, endocrinology, pharmacology, microbiology, infectious diseases, epidemiology, pediatric surgical oncology, pathology, psychology, ophthalmology, and with the oncology research laboratory. Inter-institutional research is conducted with various institutions in Mexico City, but mainly with the National University of Mexico. Currently, 21 research protocols and two international protocols are in progress.

Overall Goals
Due to the limited financial resources that our developing nation can muster, it is necessary to optimize all the active programs and protocols within the division. This will entail obtaining local/national/international funding for protocols (including cost of drugs), laboratory equipment, participation of staff in international meetings, subscriptions to appropriate medical journals, and Internet access.

We plan to continue to enhance our pediatric oncology residency program in order to maintain a high level of excellence, and further, to encourage our residents to participate not only in patient care, but also in teaching and research after finishing their training. We shall continue to encourage graduates to practice in those geographical areas in Mexico where they are most needed. We hope, also, to develop more professional links with the international community, including active participation in INCTR activities. Through such collaboration, we hope to further develop our clinical and basic research programs in order to improve our understanding and treatment of pediatric cancers.