Courageous Fight by a Patient With Burkitt's Lymphoma in Tanzania

The life of this young patient was saved through chemotherapy.

Warning Signs
The case presented here is that of a nine-year-old girl who developed a jaw swelling in April 1994. This was initially attributed, by her parents, to a recent tooth extraction.

The swelling progressively increased in size. When the parents noticed that their daughter was sitting on the sand by herself and looked very very tired while all the other children were playing in the playground, they developed an unsettled feeling which made them to take her to the nearby district hospital right away.

After examining the patient, the doctor – a medical assistant at the district hospital - suspected that the patient might have Burkitt's lymphoma but had no facilities to perform tests to confirm the diagnosis. The clinical diagnosis was conveyed to the parents. When the word cancer was mentioned, the parents were overcome with shock, fear and denial. The doctor recommended that the patient be referred to the Consultant Hospital in Dar es Salaam, which is 1,000 km from the district hospital. Since at that time it was the rainy season and most of the roads were not easily passable, it took about ten days for the family to arrive at the Consultant Hospital.

The Diagnosis

The patient and her parents had a horrible trip to Dar es Salaam. She developed malaria on the way. The deterioration in her health only emphasized the seriousness of the situation. The parents were physically and financially exhausted and could only watch in utter despair as the staff at the casualty department of the Consultant Hospital whisked their daughter off to the pediatric ward for supportive care and work-up to establish the diagnosis. The investigations included a full blood count, chest X ray, ultrasound of the abdomen and pelvis, spinal fluid examination, touch imprint and tissue biopsy. The diagnosis of Burkitt's lymphoma was confirmed in the third week of her stay at the Consultant Hospital. During the weekly Tumor Board meeting in her fourth week at the consultant Hospital, the Tumor Board recommended that the patient be transferred to the Ocean Road Cancer Institute where she was to receive her chemotherapy.

The Treatment

Burkitt's lymphoma is a very aggressive cancer but it is also exquisitely sensitive to chemotherapy. This patient's prognosis was extremely good. At the Ocean Road Cancer Institute the expected cure rate for a patient with her stage of disease is 85%. Although cytotoxic drugs are usually not affordable to most Tanzanians due to their high costs, at the Ocean Road Cancer Institute (ORCI) we have a policy of supporting all pediatric oncology patients with free chemotherapy treatment. Therefore the patient was assured of receiving the ORCI recommended combination chemotherapy despite the fact that her family could not afford to pay for the treatment.

The Victory

In July 1994 the patient was started on cyclophosphamide 30mg/kg i.v bolus, vincristine 1.4mg/m2, methotrexate 15mg/m2 and allopurinol 100mg three times a day – repeated at two weekly intervals. After four cycles the tumor had melted away. Throughout the grueling ordeal the patient gained weight and her general condition improved. We advised the patient to continue with chemotherapy for another two cycles to ensure that the cancer did not come back. In October 1994 the patient was finally free – free from intravenous fluid administration, free from the raid of cytotoxic drugs on her body, and free from disease. The mother was ecstatic. As for the patient, all she could really think about was school, home and her friends.

The Patient in 2001

The patient is well and attending secondary school. When asked what she plans to do with her life – a life she so nearly lost - she says that she intends to become a doctor.

submitted by Dr Twalib Ngoma
Ocean Road Cancer Institute,
Dar es Salaam, Tanzania