Childhood Cancer in a Developing Nation:
The Impact of a National Program

Figure 1. Pediatric patients registered in the National Program from January 2005 to June 2007.

Mexico is a country of 2 million square kilometers with a population, at the last census (2005), of 105 million inhabitants, 41% of whom are under 18 years of age. According to the last government report, 44.5 million Mexicans live below the poverty line, 14 million of whom are classified as extremely poor. The Mexican population includes 6,011,202 native Indians from various parts of Mexico, 720,000 of whom speak only their native dialect and cannot communicate in Spanish. Geopolitically, Mexico has 31 states and one federal district - Mexico City. Close to 50 million Mexicans are enrolled in socialized health care systems and close to 6 million have private medical insurance. In 2005, however, a total of 49 million people were reported by the federal government to have no health care plan.

More than half of the cases of cancer worldwide arise in developing nations¹. This imposes an enormous financial, social and health burden on countries whose available resources are severely limited, a burden that will only increase since the number of cancer cases occurring each year (including childhood cancer) is increasing rapidly. Five percent of all cancer patients in Mexicans (compared to less than one percent in high-income countries) are under the age of 18 years. The incidence of childhood cancer (0-15 years) in Mexico is 122 cases per million per year, which is similar to that observed in developed nations; it is clear that the pattern of childhood cancer has become more like that of more developed nations – due, no doubt, to other improvements in child health. For example, several analyses conducted by federal public health authorities have indicated that overall childhood mortality has diminished in Mexico. This has resulted from various interventions undertaken at a national level, including a) The National Program of Immunization for children under 6 years old; b) The National Program for Oral Hydration for infantile diarrhea; c) The early diagnosis and treatment of pneumonias at federal institutions and; d) The early medical care of high-risk pregnancies and, therefore, of high-risk newborns. All of these programs influence medical conditions that occur primarily in children under 3 years old.

Figure 2. Age distribution in 2546 children with cancer registered in the National Program (2005-2007).

Nonetheless, the overall reduction in infant mortality has resulted in a larger pediatric population at all ages, and the burden of childhood cancer has correspondingly increased. Consequently, at the present time, the second leading cause of death in Mexican children between 4 to 15 years of age is cancer². Mortality from cancer is increasing, probably due to a limited number of tertiary care medical institutions and limited human resources. Presently there are only 111 Mexican board-certified pediatric hem/oncologists nationwide. Moreover, the distribution of specialists is uneven, and there are seven states that have neither medical institutions nor trained health professionals able to provide adequate treatment for childhood cancer.

National Council for the Prevention and Treatment of Childhood Cancer (NCPTCC)

The NCPTCC program, primarily dedicated to the provision of high-quality treatment free of charge to uninsured Mexican children with cancer, was officially established in January 2005³, although during the preceding year all of the major health institutions dedicated to the treatment of childhood cancer participated in the development of treatment regimens for the ten most common childhood malignancies in Mexico. Additional objectives of the NCPTCC are to finance nationwide clinical research projects, including translational research (i.e., from “bench to bedside”) and to promote and expand pediatric oncology training programs.

Federal funding initiated in 2005 has already led to the accreditation of 36 tertiary care medical institutions in Mexico and the development of a referral system for those states that do not have medical facilities able to manage childhood cancer. A total of 60 pediatric hematologists/oncologists are working in the program throughout the country and new pediatric residency programs in childhood cancer have also been established. The first disease to be addressed, being the most common childhood cancer, was acute lymphoblastic leukemia. In January 2006, acute myeloid leukemia and solid tumors were included. All children included in the program are centrally registered online at the Mexico City Headquarters.

Figure 3. Cancer type prevalence in 2546 children from the National Program (2005-2007).

Three national meetings are held each year in order to improve the treatment regimens. By 2007, standard treatment regimens for all childhood cancers were established and, in 2008, clinical research protocols will be initiated in order to try to improve results. Currently there is a national coordinator and a committee for each type of cancer and its treatment. These working groups are kept informed of the treatment results, including toxicity, for the disease they are responsible for. Since the federal government is trying to use available funding with maximal efficiency, generic antineoplastic drugs whose quality conforms to international standards are used with results to date being comparable to those obtained with brand-name medications. The financial saving accomplished through the use of generic drugs (which includes all available anti-cancer agents not still on patent), is in the range of 60%. Between January 2005 to June 2007, a total of 2546 patients have been accrued (Figure 1). Remarkably, only 3% of registered patients have been lost to follow-up. This compares to a rate of treatment abandonment of 24% prior to the initiation of the program. Almost half the patients (46%) are between 0-4 years of age (Figure 2) and more than half (51%) have leukemia or lymphoma (Figure 3).

In conclusion, this national program, if current progress can be continued, will eventually include all uninsured children with cancer throughout Mexico. It will also lead to improvements in patient care and promote clinical research through the creation of a cooperative group. A national group of this kind will be of great value in developing treatment strategies that lead to optimal patient care in the context of limited financial resources⁴.

Roberto Rivera-Luna
National Institute of Pediatrics
Mexico City, Mexico

References

1. Eden T, Pui Ch, Schrappe M, et al. All children have a right to full access to treatment for cancer. Lancet 364:1121-2,2004.
2. Abdullaev FI, Rivera-Luna R, Roitenburd-Balacortu V, et al: Pattern of Childhood Cancer Mortality in Mexico. Arch Med Res 31;526-31, 2000.
3. Rivera-Luna R, Cardenas-Cardos R,
Martinez-Avalos A, Leal-Leal C, Olaya-Vargas A,Castellanos-Toledo A, Niembro-Zuńiga A. Childhood cancer in a developing nation. J. Clin. Oncol. 25;1300-1, 2007.
4. Howard SC, Ribeiro RC, Pui CH. Strategies to improve outcomes of children with cancer in low income countries. Eur J Cancer 41;1584-7, 2005.