Hematology and Pediatric Hemato-Oncology Services in Casablanca

The Children's Hospital in Casablanca.

The Country, the City and the People
The Kingdom of Morocco, situated at the northwest tip of Africa and bordered by the Atlantic ocean and the Mediterranean sea, covers an area of 710,850 km². The population exceeds 31 million, with children under the age of 14 representing almost 40% of the population. Morocco faces the problems typical of developing countries: 19% of the population living below the poverty line and up to 50% being illiterate.

Casablanca is the capital; with more than 4 million inhabitants, it is the most densely populated city in North Africa. More than 60% of Morocco's economic activity is concentrated there.

Hematology and Pediatric Oncology
The Department of Hematology and Pediatric Hemato-Oncology was created in 1980 by Professor N Benchemsi and Professor S Benchekroun, at a time when there was no specialized unit in Morocco dealing with hematological malignancy. Given the inadequate quality of supportive care facilities, specifically the lack of blood products and antibiotics, intensive chemotherapy was not used. Most patients had no health insurance and could not afford to pay for their treatment. Likewise, the hospital had very limited resources and could not provide such expensive treatment. It thus became clear that quality of care would not improve without additional help. An association of volunteers and donors was therefore established in 1983. Named ‘Agir,' it has proven to be very efficient and has helped the hospital team in its endeavors to provide optimal care.

Unfortunately, the Department in Casablanca is still the only public facility in Morocco treating adult patients with hematological malignancies. Two pediatric units have been established, one at the Children's Hospital in Casablanca, the other in Rabat. The Department comprises an outpatient clinic and a day-care unit, where more than 100 patients are seen each day, together with two wards—one with 24 beds for adults the other with 13 beds for children. Mothers are encouraged to stay with their children.

Each year, the Department admits more than 1,000 new patients, of whom approximately 250 are children suffering from various kinds of cancer. Lymphomas, leukemias, myeloma and aplastic anemia, together with ‘benign' conditions such as iron deficiency anemia, thalassemia, sickle cell anemia, and hemophilia, are the most prevalent conditions seen in adults, whereas in children, lymphomas, acute lymphoblastic leukemia (ALL), nephroblastoma, neuroblastoma and bone tumors are the most frequently seen malignancies.

Improvements in Supportive Care
Improvements in supportive care have resulted in a significant decrease in mortality from neutropenic sepsis. Initially this was 30%, but a retrospective analysis of 40 febrile episodes in children with AML treated between 1996 and 2001 showed the mortality rate to have fallen to 5% in an era when more intensive treatment was being used. In the initial series of 66 patients treated between May 1980 and January 1983, when hydroxyurea was the only drug being used, complete remission (CR) was achieved in only 5 patients. In contrast, CR was achieved in 15 of 20 patients admitted during 2002. Current treatment comprises remission induction therapy with daunorubicin and cytarabine (ara-C), followed by 2 cycles of high-dose ara-C, given with doxorubicin or idarubicin.

This progress has been made possible by improvements in supportive care, increased awareness of the importance of hygiene, education of patients and improvements in nursing education. Another factor has been the quality of blood products: a Quality Control Committee for Blood Transfusion Services sees to this. Screening for hepatitis B and C and for HIV is now routinely carried out. As a result, the incidence of hepatitis C has fallen from 26% to 6% in patients receiving multiple transfusions. Morocco has a very low incidence of HIV, but an Infection Control Committee, which works closely with the medical staff, has been established.

Lymphoma
In view of the potentially good prognosis of patients with lymphoma, this group of diseases was considered to be a priority and resources were allocated to improve survival in these patients. Ninety-five patients with Burkitt's lymphoma (mean age 6.7 years, male: female ratio 1:2.5) have been treated according to the French LMB89 protocol. Most patients (73.5%) had an abdominal presentation; the diagnosis was made on the basis of fine needle aspiration in 60% of cases. The majority of cases (63%) had Stage III disease. Complete remission was achieved in 68.5% of cases and the five-year survival was 59%. Ten of the 15 patients who died did so before or shortly after initiation of treatment due to metabolic and nutritional complications.

The greatest problem is that patients present with very advanced disease because of delays in diagnosis and the long distances involved in reaching the hospital. For example, 441 adults were treated for non-Hodgkin's lymphoma between January 1998 and December 2000. Only 39 of them live in Casablanca. Only 10% had health insurance. The mean duration of symptoms before diagnosis was eight months; 70% had Stage III or IV disease at the time of presentation.

With regard to Hodgkin's disease, 181 children have been treated up to 2001. Chemotherapy regimens comprised ‘MOPP', ‘COPP' or ‘ABV.' In 1986, a phase II study was conducted to evaluate the use of vinorelbine. Again, most patients presented with advanced stage disease. An unexpected finding was the incidence of Hodgkin's disease in very young children; 15 being 4 years or younger at the time of presentation.

Accomplishments and Collaborative Programs
The Department is a major referral center for the treatment of children with cancer and for adult patients with hematological disorders. We have participated in the creation of the Moroccan Society of Pediatric Oncology (SMOP) and have worked in collaboration with the Center for Pediatric Oncology in Rabat (Professor Msefer-Alaoui) in the organization of the third SIOP meeting of Africa. We have organized 13 workshops in hematology and pediatric oncology.

Currently there is no stem cell transplantation program in Morocco. With the help of our fundraising group we are working to set up a small unit for this purpose. We are also lucky to have been involved with Professor Jean Lemerle (Villejuif, France) in the Groupe Franco-Africain d'Oncologie Pédiatrique. The group is focusing on Burkitt's lymphoma and Wilms tumor.

We also have developed an ambitious program with the International Outreach Program of St Jude Children's Research Hospital (USA), directed by Dr Judith Wilimas and Dr Raul Ribeiro. This program has focused on nursing, together with improvement in pathology services and infection control, as well as data management, ethical issues, immuno-phenotyping for leukemia and the development of therapeutic protocols adapted to local circumstances.

The medical care provided at Children's Hospital in Casablanca, which focuses on both the physical and emotional needs of young patients, gets a "thumbs up."

What next?
There are several aspects of treatment which need improvement, including cytogenetics and services for the treatment of thalassemia, sickle cell anemia and hemophilia. Since there is no reliable data on the epidemiology of cancer in Morocco, a cancer registry is urgently needed. There is also a need for the creation of other units throughout the country to take care of children suffering from cancer; we will be helping with the establishment of this program. Finally, since there is no accommodation for the parents of children in the hospital, the fundraising group is working to remedy this.

The medical team is very dedicated and enthusiastic and is extremely interested in developing collaborative projects with experienced teams in hematology and pediatric oncology.