UNVERSITY OF GHANA SCHOOL OF MEDICINE AND

DENTISTRY

COLLEGE OF HEALTH SCIENCES

COMMUNITY HEALTH DEPARTMENT

THE MUTATION IN NUMBERS: EPIDEMIOLOGICAL STUDIES

AND GEOGRAPHICAL ANALYSIS OF CHILDHOOD CANCER

CASES PRESENTING AT KORLE BU TEACHING HOSPITAL

(KBTH)

BY

DENU KWAKU INNOCENT MAWULORM,

(B Sc. MEDICAL SCIENCES)

A DISSERTATION PRESENTED TO THE DEPARTMENT OF

COMMUNITY HEALTH, UNIVERSITY OF GHANA SCHOOL

OF MEDICINE AND DENTISTRY IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE AWARD OF THE MBChB

DEGREE

AUGUST 2015

  I  

DECLARATION

I HEREBY DECLARE THAT APART FROM THE CITED

LITERATURE THIS PROJECT REPORT WAS CONDUCTED BY ME

AT THE DEPARTMENT OF COMMUNITY HEALTH, UNIVERSITY

OF GHANA SCHOOL OF MEDICINE AND DENTISTRY OF THE

COLLEGE OF HEALTH SCIENCES, KORLE BU UNDER THE

SUPERVISION OF DR. ROSEMARY RICHARDSON.

STUDENT’S SIGNATURE:………………………………….

DATE:…………………………

DISSERTATION REVIEWED AND ACCEPTED

BY:…………………………….

SUPERVISORS NAME: DR. ROSEMARY RICHARDSON

SIGNATURE...............................

DATE..........................................

  II  

DEDICATION

This research is dedicated to all children with cancer across the world.

To the memory of my friend Gadagoe Gorby, who died of cancer a year ago. RIP

  III  

ACKNOWLEDGEMENT

I give thanks to GOD almighty for His abundant grace and guidance throughout my

years of schooling.

To my family, for the support in the form of encouragement, prayers through my

many years of medical school, and provision of funds for this research.

I also wish to thank the following individuals who assisted me in diverse ways with

this thesis:

- My research supervisor, Dr.Rosemary Richardson of the Department of Community

Health, University of Ghana, School of Medicine and Dentistry.

- Professor Lorna Renner, head of the Pediatric Oncology Unit of Korle Bu Teaching

Hospital

- The Staff of the Pediatric Oncology Unit especially Mr. Emmanuel Amankwah

- My friends for their support.

God bless you all.

  IV  

TABLE OF CONTENTS.

Declaration……………………………………………………………………….I

Dedication……………………………………………………………………….II

Acknowledgement………………………………………………………………III

Abstract………………………………………………………………………….IV

Table of Contents………………………………………………………………..V

List of figures…………………………………………………………………....VI

List of tables………………………………………………………………….....VIII

Abbreviations……………………………………………………………………IX

Abstract………………………………………………………………….............X

CHAPTER ONE- INTRODUCTION.……………………………………..….1

1.1 Background…………………………………………………………..………1

1.2 Problem statement………………………………………………..…………..1

1.3 Rationale……………………………………………………...……………....2

1.4 Aim………………………………………………………...………………....3

1.5 Objectives……………………………………………...……………………..3

CHAPTER TWO –LITERATURE REVIEW.……………………………….4

2.0 Introduction……………………………………………………………….….4

2.1 Common Cancers of Children.………………………………………….……6

2.2 Aetiology of Childhood Cancers.…………………………………….………8

2.3 Classification of Childhood Cancers.…………………….………………….10

2.4 Epidemiology of Childhood Cancers.…………………….…………………13

2.5 Treatments and Support For Childhood Cancers in Ghana..………………..16

2.6 Survival Rates of Childhood Cancers in Africa.……………………………17

2.7 The Way Forward.…………………………………………………………..19

CHAPTER THREE-METHODOLOGY.……………………………………20

3.0 Study design.………………………………………………………………..20

3.1 Sampling strategy.………………………………………………………..…20

3.2 Study area.………………………………………………………………......20

3.3 Study population.………………………………………………………...….20

  V  

3.4 Inclusion Criteria.…………………………………………………………….21

3.5 Exclusion Criteria.……………………………………………………………21

3.6 Consent and Ethical issues.…………………………………………………..21

3.7 Data collection instruments and methods.…………………………………...21

3.8 Data handling, analysis and presentation.……………………………………21

CHAPTER FOUR- RESULTS.………………………………………………..22

CHAPTER FIVE- DISCUSSION.…………………………………………….42

5.0 Introduction………………………………………………………………….42

5.1 Incidence Rate Per Million Children………………………………………...42

5.2 Sex Distribution……………………………………………………………..42

5.3 Most Common Cancer Types Diagnosed…………………………………...42

5.4 Age characteristics of Patients………………………………………………45

5.5 Ethnic Variation of Patients…………………………………………………45

5.6 Geographical Analysis………………………………………………………45

5.7 Regional Referral Variations………………………………………………...47

CHAPTER SIX- RECOMMENDATIONS ………………………………….48

6.0 Introduction…………………………………………………………………48

6.1 Need For A National Cancer Registry……………………………………...48

6.2 Public Education and National Awareness Programs………………………48

6.3 Improving Access to Proper Healthcare…………………………………….48

6.4 Reducing Cost Of Cancer Treatment……………………………………….49

6.5 Call For Research Into Childhood Cancers…………………………………49

CHAPTER SEVEN- CONCLUSION………………………………………..50

REFRENCES…………………………………………………………………..51

APPENDIX.........................................................................................................55

Pediatric Oncology Registry Form Sample……………………………………..55

  VI  

LIST OF FIGURES

FIGURE 4.1 A BAR CHART SHOWING THE NUMBER OF CASES OF

CHILDHOOD CANCERS AT KBTH REFERRED FROM THE VARIOUS

REGIONS…………………………………………………………………………23

FIGURE 4.2 A PIE CHART SHOWING THE DISTRIBUTION OF CHILDHOOD

CANCERS AT KBTH BY SEX………………………………………………….26

FIGURE 4.3 A LINE GRAPH SHOWING THE PATTERN OF INCIDENCE OF

CHILDHOOD CANCERS AT KBTH…………………………………………...30

FIGURE 4.4 A DOUGHNUT SHOWING THE DISTRIBUTION OF CHILDHOOD

CANCER CASES AT KBTH BY ETHNIC

BACKGROUND…………………………………………………………………33

FIGURE 4.5 A BAR CHART SHOWING THE URBAN-RURAL DISTRIBUTION

OF CHILDHOOD CANCER CASES AT

KBTH…………………………………………………………………………….34

FIGURE 4.6 A PIE CHART SHOWING THE TYPES OF LYMPHOMAS

DIAGNOSED……………………………………………………………………35

FIGURE 4.7 A BAR CHART SHOWING THE ANCESTRAL BACKGROUND OF

PATIENTS DIAGNOSED WITH LYMPHOMAS……………………………..36

FIGURE 4.8 A PIE CHART SHOWING THE RURAL-URBAN RESIDENTIAL

DISTRIBUTION OF PATIENTS WITH BURKITT’S LYMPHOMA AT

KBTH……………………………………………………………………………37

FIGURE 4.9 A PIE CHART SHOWING THE RURAL-URBAN RESIDENTIAL

DISTRIBUTION OF PATIENTS WITH OTHER TYPES OF LYMPHOMA AT

KBTH…………………………………………………………………………...38

  VII  

FIGURE 4.10 A PIE CHART SHOWING THE TYPES OF LEUKEMIA

DIAGNOSED……………………………………………………………………39

FIGURE 4.11 A BAR CHART SHOWING THE ANCESTRY OF PATIENTS

DIAGNOSED WITH LEUKEMIA…………………………………………….40

FIGURE 4.12 A PIE CHART SHOWING THE RURAL-URBAN RESIDENTIAL

DISTRIBUTION OF PATIENTS WITH LEUKEMIA AT

KBTH…………………………………………………………………………….41

  VIII  

LIST OF TABLES

TABLE 4.1 A TABLE SHOWING SOME CALCULATED STATISTICS FOR

PATIENTS…………………………………………………………………………22

TABLE 4.2 A TABLE SHOWING CALCULATED INCIDENCE OF CHILDHOOD

CANCERS PER MILLION CHILDREN…………………………………………22

TABLE 4.3 A TABLE SHOWING THE DISTRIBUTION BY DIAGNOSIS OF

CHILDHOOD CANCERS AT KBTH……………………………………………25

Table 4.4 A TABLE SHOWING THE DISTRIBUTION OF CHILDHOOD

CANCERS AT KBTH BY AGE GROUP AND SEX……………………………27

TABLE 4.5 TABLE SHOWING SEX DISTRIBUTION OF

NEPHROBLASTOMA……………………………………………………………27

TABLE 4.6 A TABLE SHOWING THE SEX DISTRIBUTION OF THE VARIOUS

CHILDHOOD CANCER TYPES DIAGNOSED AT KBTH……………………28

TABLE 4.7 A TABLE SHOWING THE DISTRIBUTION OF CHILDHOOD

CANCERS AT KBTH BY AGE GROUP ……………………………………….29

TABLE 4.8 A TABLE SHOWING THE MOST COMMON CHILDHOOD

CANCER TYPES AMONG VARIOUS AGE GROUPS AT KBTH…………..31

TABLE 4.9 A TABLE SHOWING DISTRIBUTION OF CHILDHOOD CANCERS

AT KBTH BY NATIONALITY………………………………………………...32

  IX  

ABBREVIATIONS

KBTH: KORLE BU TEACHING HOSPITAL

WHO: WORLD HEALTH ORGANISATION

AML: ACUTE MYELOID LEUKEMIA

ALL: ACUTE LYMPHOBLASTIC LEUKEMIA

CML: CHRONIC MYELOID LEUKEMIA

NHL: NON-HODGKIN’S LEUKEMIA

ICCC: INTERNATIONAL CLASSIFICATION OF CHILDHOOD CANCERS

HIV: HUMAN IMMUNODEFICIENCY VIRUS

  X  

ABSTRACT

BACKGROUND: There has been an increase in childhood cancer cases worldwide.

Over a 1000 cases of childhood cancers are diagnosed in Ghana annually. In Western

Africa, non-Hodgkin’s lymphomas were the commonest in Ghana [1]. The other

common cases that present at the pediatric oncology unit of KBTH are leukemia and

retinoblastomas and nephroblastomas.

AIM: This study was undertaken to determine epidemiology of childhood cancer

cases presenting at KBTH pediatric oncology between January 2014 and December

2014

SUBJECTS AND METHODS: This study was a descriptive study analyzing routine

hospital records and oncology registry forms of the cases of childhood cancers seen at

the pediatric oncology unit of KBTH. Data were analyzed using SPSS version 22 and

the results expressed as counts, percentages, tables and graphs.

RESULTS: Childhood cancer cases at KBTH have remained at about the same level

over the past 5 years. A total of 127 cases were diagnosed in 2014 with an incidence

of 12.8 per million children.

The cancer cases were more common in male children with a male to female ratio of

1.3:1.

Lymphomas were the most common type of cancer diagnosed. However the incidence

of Burkitt’s lymphoma has seen a decline over the years.

Leukemia, retinoblastoma and nephroblastoma were the next most common cancer

types.

Most patients were residents of urban and peri-urban communities and most cases

were from within the Greater Accra region

CONCLUSION: The number of childhood cancer cases diagnosed at KBTH remains

significantly high. There is the need for concerted national efforts in developing a

registry and advocacy towards improving the accessibility and quality of childhood

cancer care nationwide.

  1  

CHAPTER ONE

INTRODUCTION

1.0 BACKGROUND

There has been an increase in childhood cancer cases worldwide. Over a 1000 cases

of childhood cancers are diagnosed in Ghana annually. In Western Africa, non-

Hodgkin’s lymphomas were the commonest in Ghana [1]. The other common cases

that present at the pediatric oncology unit of KBTH are leukemia and retinoblastomas

and nephroblastomas.

Genetic factors as well as environmental factors have been implicated as the main

causes of cancer among children although a lot is still not understood.

Socio economic status, malnutrition, exposure to viral infections and malaria are

thought to play important roles in cancer pathology and clinical characteristics. [2] .

1.1 PROBLEM STATEMENT

With the advent of vaccines and other interventions against infectious diseases, non-

communicable diseases such as cancers are becoming a major disease burden among

children. With the increasing success of the Expanded

Programme on Immunisation (EPI) and some improvements in socio-economic status,

there has been a reduction of childhood infectious diseases, therefore, paediatric

non-communicable diseases including malignancies have become increasingly

important [3, 4]

Epidemiological studies and geographical analysis will help identify trends in age of

presentation and environmental factors that predispose or are associated with the

incidence of childhood cancers in Ghana. This will be helpful in the development of a

national population-based tumor registry, which is an essential tool in obtaining

information about age-specific incidences, relative frequencies of various neoplasms,

prevalence of children’s cancers and individual malignancies and their distribution

according to age, sex, ethnicity and geographical area [5].

  2  

1.2 RATIONALE

There has been limited study in Ghana on childhood cancer cases although there has

been an increase in the number of cases over the past decade. There is also no

National Registry of Childhood Tumours (NRCT) to collect relevant information on

incidence, management and follow-ups of these cases.

Epidemiological studies and geographical analysis of childhood cancer cases

presenting at Korle Bu Teaching Hospital (KBTH) paints the picture of real lives

affected and present data on the cases and set to provoke more study into childhood

cancer cases in Ghana.

With the national strategy for cancer control document in Ghana (2012-2016)

document, the Ministry of Health is aiming at reducing cancer incidence and

mortality, adopting a WHO model of published guidelines for effective cancer control

programs in six modules: planning, prevention, early detection, diagnosis and

treatment, palliative care, and policy and advocacy. A national cancer control plan

developed is aimed at accelerating the national drive to combat cancer. This

development is an encouraging one and this study is to help encourage the

conversation about childhood cancers. Providing relevant data to back the call for

action, now more than ever.

This study is intended as a reference for policy makers, service providers, educators,

students, researchers, advocates, and others interested the knowledge about childhood

cancers.

This information can be used as a document to show the need to prioritize research,

and to support the need for national effort and calls for services for those who have

been diagnosed, have been or are being treated, those who live with disabilities from

treatment and those who have lost loved ones to childhood cancers.

  3  

1.3 AIM

The study aims to determine epidemiology of childhood cancer cases presenting at

KBTH pediatric oncology between January 2014 and January 2015.

1.4 OBJECTIVES

To determine the incidence per million children of childhood cancers

To determine the demographic characteristics of patients with childhood cancers

To do a rural-urban geographical analysis of the cases of childhood cancers

presenting at KBTH.

  4  

CHAPTER TWO

LITERATURE REVIEW

2.O INTRODUCTION

Childhood cancers are a group of solid tumors and other forms of cancers with

different clinical manifestations and varied presentations. Usually associated with

poor prognosis, cancers in children are not a physician’s fairy tale.

Globally, about 160,000 new cases of cancers are diagnosed in children under 15 a

year, with some 90,000 deaths a year [6].

In developed countries, childhood cancers are considered among top causes of all

childhood deaths. Cancer is the second most common cause of death in children in

Western countries. However, in Africa it is not ranked among top causes of death

among children. Infections, malnutrition, HIV and tuberculosis still stand the most

important paediatric health problems in developing countries.

Childhood cancers are however not as rare as in the past. With the introduction of

immunization programmes, prevention of mother to child transmission of HIV and

other childhood survival strategies adopted across the African continent, life

expectancy has increased and with it the incidence of non-infectious illnesses across

all age brackets. With increasing number of doctors and better accessibility to health

care, these cancers are now more easily recognized and diagnosed.

Contrary to most malignant diseases in adults, pediatric cancer is less associated with

modifiable environmental or lifestyle factors, but rather with genetic abnormalities

and are therefore not amenable to population-based screening and prevention

programs [9]. Therefore, they are almost not preventable.

Beyond all that can be said about neglect of human rights, not allocating sufficient

resources to pediatric oncology is also economically short-sighted, as childhood

cancer is highly curable and up to 80% of the treated children will attain adulthood

and be productive [7]. In developed countries, more than 80% of children with

  5  

malignancies can be cured. Unfortunately a lot of the children with cancer live in low

and middle-income countries, where the cure rate is much lower. [8]

In first world countries more than 70-80% of children with cancer become long- term

survivors [10]. For some childhood cancers 5-year survival rates approach 95% [11].

Unfortunately the story is not the same in developing countries like Ghana. There are

many obstacles to early diagnosis and effective treatment of childhood cancer in

Ghana and other African nations. Scanty resources, late presentation of disease, co-

morbid conditions (such as HIV) and malnutrition are among the barriers preventing

improvement in survival [12]

In Ghana, the story is not different from the rest of the African continent. The number

of childhood cancer cases diagnosed at KBTH has increased significantly over the

past two decades. Childhood cancer care needs to be prioritized and efforts to increase

public awareness, improve diagnostic capacity and increase access to cancer treatment

should be intensified [2].

  6  

2.1 COMMON CANCERS OF CHILDREN

The most common cancers in children are leukemias, lymphomas, retinoblastomas,

solid tumours like nephroblastomas (Wilm’s tumour) and neuroblastomas.

LEUKEMIAS are the most common type of cancers in children worldwide.

Leukemias are heterogeneous neoplastic disorders of the white blood cells. They can

be divided into myeloid or lymphoid based on the cell of origin. Also can be acute or

chronic. Acute leukemias are usually fast and a more aggressive presentation than

chronic leukemias, which may be asymptomatic. Acute leukemias are more common

in children.

Acute myeloid leukemia is a disorder of the hematopoietic precursor cells. It mainly

presents with progressive anaemia, leukopenia and thrombocytopenia.

Acute lymphocytic leukemia is a disorder of the lymphopoeitic precursor cells. This

leads to progressive accumulation of lymphoblasts in the medullary and extra-

medullary spaces. There is also associated disorder of normal development of the

hematopoietic cells. Recurrent infections secondary to leukopenia, progressive fatigue

secondary to anaemia are the main symptoms.

Chronic myeloid leukemia is due to uncontrolled proliferation of granulocytes.

patients may be asymptomatic but may present with weight loss, bleeding and

splenomegaly.

Chronic lymphocytic leukemia is clonal disorder of lymphocytes. This could be of B-

cells or T-cells. There is bone marrow involvement and secondary release into

peripheral blood. The circulating lymphocytes infiltrate lymph nodes, spleen and liver

resulting in lymphadenopathy, splenomegaly and hepatomegaly. Secondary

immunodeficiency may result from hypogammaglobulinemia.

LYMPHOMAS are lymphoproliferative disorders of white cells, mainly classified as

Hodgkin and non-Hodgkin’s lymphomas.

Hodgkins lymphomas are potentially curable lymphomas with distinct histology,

biologic behavior and clinical preentations. Classical Hodgkin’s lymphomas have the

characteristic Reed-Sternberg cells which are cells of B-cell origin derived from

germinal centres of lymph nodes but no longer able to produce antibodies.

  7  

Hodgkin’s lymphomas present with lymphadenopathy, unexplained weight loss, fever

and night sweats. Pruritus, bone pain, and shortness of breath are also common

symptoms. Painless lymphadenopathy with splenomegaly plus or minus

hepatomegaly is common examination findings.

Non-Hodgkin’s lymphoma arises mainly from lymph nodes. The median age of

diagnosis is the sixth decade. Burkitts lymphoma and lymphoblastic leukemia

however occur in younger children.

Burkitts lymphoma is a highly aggressive B-cell non-Hodgkin’s lymphoma. It has a

rapid and aggressive clinical course with frequent CNS and bone marrow

involvement.

It presents with fast growing jaw and facial tumours usually. Abdominal tumours are

also common.

WILM’S TUMOUR OR NEPHROBLASTOMAS are the most common childhood

abdominal tumours. The median age of diagnosis is about 3.5 years. Presentation is

usually an asymptomatic abdominal mass. There may an associated abdominal pain,

haematuria, hypertension, anaemia and fever.

RETINOBLASTOMAS are ocular tumours arising from multipotent precursor cells

that develop into almost any type of inner or outer retinal cell. Retinoblastomas are

diagnosed at an average age of 18months with over 90% of cases diagnosed before

age 5. Leukocoria or ‘cat’s eye’ is usually the early presentation. There may be

associated strabismus with visual loss and proptosis. Retinoblastomas cause

secondary changes in the eye such as glaucoma, retinal detachment and inflammation.

  8  

2.2 AETIOLOGY OF CHILDHOOD CANCERS

A wide range of factors has been attributed to cancers in children. There is a

hypothesis that cancer is multifactorial in origin, which is generally accepted [5]. The

risk factors attributed to cancers in children have been extensively studied, mostly in

North America and Europe. The factors can be said to be in known, suggestive and

those with limited evidence. Some factors have also been found to no conclusive

evidence after many studies.

The known risk factors include genetic factors, congenital disorders, gender,

environmental factors, ethnicity and age-peak. Ethnic variations confirm the

possibility of genetic factors with higher incidence of bilateral retinoblastomas in

people of Arab descent, and decreased incidence of renal tumours in Asians and

sympathetic nervous system cancers in blacks [14,15]. However only about 5% of

childhood cancers can primarily be attributed to a genetic predisposition and the

etiology of most childhood cancers remain unknown [16].

Many infections especially of viral origin, immunodeficiency states and

environmental factors such as ionizing radiation, some drugs and other chemicals

have all been implicated. What is clear is that, these factors are usually non-

modifiable and little prevention measures can be adopted unlike in adults.

Leukemias have been attributed to multiple factors, of which the final common

pathway is the damage to DNA. Chromosomal anomalies such as trisomies 21

(Down’s syndrome) and the Philadelphia chromosome, an abnormality of

translocation on the long arm of chromosome 22 have strong association with

leukemias.

Burkitt’s lymphoma is associated with translocation between chromosome 8 and

deregulation of c-myc gene on chromosome 8. The t (8; 14)(q34; q 32) is the most

common of these translocations. Others are the t (2;8)(p12; q 24) and

t(8;22)(q24;q11).

  9  

Wilms tumour is associated with the WT1 gene, a suppressor gene on chromosomal

band 11p13. Knudson and Strong discovered this after a study by in 1970s in children

with Wilms tumour, aniridia, genitourinary anomalies and mental retardation (WAGR

syndrome)

Epstein-Barr virus (EBV) infection has been closely associated with the development

of Burkitt’s lymphomas and some Hodgkin’s lymphomas.

Malaria infection also has close relationship with Burkitt’s lymphoma hence the

endemic African type (eBL).

HIV- positive patients and those with other forms of immunosuppression have higher

risk of childhood cancers especially lymphomas and Kaposi sarcomas.

There is a strong positive family history of occurrence of retinoblastomas, especially

in the bilateral types.

In-utero exposure to radiation and prior chemotherapeutic agents are also known risks [16] with ionizing agents and alkylating agents being highly implicated

Other factors suggested are maternal reproductive factors. Maternal age above 35 is

associated with many fetal anomalies and syndromes such as Downs syndrome,

which come with increased risk of malignancies such as leukemias. Preterm delivery

is also associated with higher risk of germ cell tumour, and low birth weight

associated with hepatic tumours. Maternal alcohol intake and smoking has been

linked to higher risks of sympathetic nervous system tumours. These are however

mere associations with no proven scientific basis as at yet but remain relevant in

evaluating cases of childhood cancers.

Environmental exposure to smoking and pesticides has been suggested to have links

to some cancers. Parental occupational exposures have also been looked at to have

some associations with subsequent development of cancers among offspring.

  10  

2.3 CLASSIFICATION OF CHILDHOOD CANCERS

The classification of childhood cancers, has been established to be based on

morphology of cancer cells rather than the primary site of origin as in adults.

The International Classification of Childhood Cancers (ICCC) is based on

morphology and primary site with an emphasis on morphology than emphasis on

primary site as in adults.

The Main and Extended Classification For ICCC Recode ICD-O-3/WHO 2008 [17] is

a table updated for hematopoietic codes based on the WHO Classification of Tumours

of Haematopoietic and Lymphoid tissues (2008). This table classifies childhood

cancers as follows:

1. Leukemias, myeloproliferative diseases and myelodysplastic diseases. This

includes

A) Lymphoid leukemias like precursor cell leukemias, mature B-cell leukemias and

mature T-cell and NK-cell leukemias .

B) Acute myeloid leukemias

C) Chronic myeloid leukemias

D) Myelodysplastic syndrome and other myeloproliferative diseases

E) Unspecified and other specified leukemias.

2.Lymphomas and reticuloendothelial neoplasms which include:

A) Hodgkins lymphomas

B) Non-Hodgkins lymphomas except Burkitts’s lymphoma like precursor cell

lymphomas (B1), mature B-cell lymphomas except Burkitt’s lymphoma (B2), mature

T-cell and NK-cell lymphomas (B3) and Non-Hodgkin’s lymphomas, not otherwise

specified (B4).

C) Burkitt’s lymphoma

D) Miscellaneous lymphoreticular neoplasms

E) Unspecified lymphomas

3. CNS and miscellaneous intracranial and intraspinal neoplasms. This include

A) Ependymomas and choroid plexus tumours. They are made up of ependymomas

(A1) and choroid plexus tumours (A2).

B) Astrocytomas

  11  

C) Intracranial and intraspinal embryonal tumours consisting of

medulloblastomas(C1), PNET(C2), medulloepithliomas(C3), atypical teratoid

rhabdoid tumors(C4).

D) Other gliomas. They include oligodendrogliomas, mixed and unspecified

gliomas(D1), neuroepithelial(D2), glial tumours of uncertain origin(D3).

E) Other specified intracranial and intraspinal neoplasms. In this category are

pituitary adenomas and carcinomas (E1), tumors of the sellar region also called

craniopharyngiomas (E2), pineal parenchymal tumours(E3), neuronal and mixed

neuronal-glial tumours(E4) and meningiomas(E5)

F) Unspecified intracranial and intraspinal neoplasms.

4. Neuroblastomas and other peripheral nervous cell tumours. They consist

A) Neuroblastomas and ganglioneuroblastomas

B) Other peripheral nervous cell tumours

5. Retinoblastomas

6. Renal tumours. These are made up of

A) Nephroblastomas and other non epithelial renal tumors. They are

nephroblastomas(A1) and rhabdoid renal tumours(A2), kidney sarcomas(A3) and

pPNET of kidney(A4).

B) Renal carcinomas

C) Unspecified malignant renal tumours

7. Hepatic tumours. In this group are

A) Hepatoblastoma

B) Hepatic carcinomas

C) Unspecified malignant hepatic tumours

8. Malignant bone tumours:

A) Osteosarcomas

B) Chondrosarcomas

C) Ewing tumours and related sarcomas of the bone. This include Ewing tumour and

Askin tumour of the bone (C1) and pPNET of bone (C2)

D) Other specified malignant bone tumours made up of malignant fibrous neoplasms

of the bone (D1), malignant chordomas (D2), odontogenic malignant tumours(D3)

and miscellaneous malignant bone tumours(D4).

E) Unspecified malignant bone tumours.

  12  

9. Soft tissues and other extraosseous sarcomas

A)Rhabdomyosarcomas

B) Fibrosarcomas, peripheral nerve sheath tumors, and other fibrous neoplasm which

include fibroblastic and myofibroblastic tumors(B1), nerve sheath tumors(B2) and

other fibromatous neoplasm(B3)

C) Kaposi sarcoma

D) Other specified soft tissue sarcomas

10. Germ cell tumors, trophoblastic tumors, and neoplasms of gonads

A) Intracranial and intraspinal germ cell tumors

B) Malignant extracranial and extragonadal germ cell tumors

C) Malignant gonadal germ cell tumors

D) Gonadal carcinomas

E) Other and unspecified malignant gonadal tumors

11. Other malignant epithelial neoplasms and malignant melanomas

A) Adrenocortical carcinomas

B) Thyroid carcinomas

C) Nasopharyngeal carcinomas

D) Malignant melanoma

E) Skin carcinomas

F) Other and unspecified carcinomas

12. Other and unspecified malignant neoplasms

A) Other specified malignant tumors

B) Other unspecified malignant tumors

  13  

2.4 EPIDERMIOLOGY OF CHILDHOOD CANCERS.

Over the past decades there has been a lot of research into paediatric oncology. The

majority of this research, however, has been in developed countries [18]. Countries

such as the United States and Sweden have well developed registries, which have data

readily available for planning of programmes for children with cancers. The United

States’ National Cancer Institute, for example, has the Surveillance, Epidemiology

and End Results (SEER) Programme, which collects data from all over the country,

and extrapolates this to determine national childhood cancer data [19]. From their data,

leukaemias are the commonest cancer in children aged 0 to 14 years, with an

incidence rate of 50.5 per million, followed by brain and spinal tumours at 37.3 per

million and lymphomas at 15 per million (2001 to 2004). 5-year survival rates for

childhood cancers reached 78% (80% for leukaemias, 70% for brain and spinal

tumours and 87% for lymphomas). Retinoblastoma had 5-year survival rates of as

high as 97% (1996 to 2003) [20]

The annual incidence of childhood cancer was estimated to be between 33.4 and 47.2

per million between 2003 and 2007. Information about childhood cancer in Africa is

lacking, because there are few formal cancer registries across the continent. The

South African Children’s Tumour Registry was established in 1987 at the initiative of

SACCSG and is the only one in Africa dedicated exclusively to childhood cancer [5].

Incidence rates of cancer differ from country to country. Incidence also differs

between various ethnic groups within a single country, and between various countries

with similar ethnic compositions. Such differences may be the result of differences in

genetic predisposition, exposure to infectious diseases, and other environmental

factors [21].

In their 1998 publication “pattern of childhood malignancy in Korle-Bu teaching

hospital, Ghana”, Welbeck JE and Hesse AA found that 254 cases of childhood

cancers had been diagnosed over a 40-month period. They also noted that Lymphoma

was the commonest tumour constituting 67% with Burkitt's lymphoma being the

commonest subtype, which was followed by Retinoblastoma (8.6%), Leukaemia

(8.2%) and Wilms tumour (7.8%) [2].

  14  

A more recent four-year study from 2008 to 2011 at KBTH by Segbefia et al found

that 495 cases of childhood cancers were diagnosed, making an average of 124 new

cases per year [22] in Ghana, and a male to female ratio of 1.3: 1.

In another retrospective study spanning 10 years which used cause of death from

childhood malignancy after autopsies, Gyasi R K and Tetteh Y. found that a total of

252 cases of childhood malignant tumours were retrieved, 139 males and 113 females

with a male to female ratio of 1.2:1[23].

In Nigeria, a study in Kano by Ochicha O. et al found a total of 438 cases of

childhood cancers diagnosed over a 10-year period from 2001 to 2010 [6] with a slight

preponderance with a ratio of 1.3:1. Retinoblastomas were the most common cancer

type diagnosed with about a third of all cases diagnosed being ocular tumours.

Burkitts lymphomas and leukemias were the second and third highest respectively.

Most of the cases were diagnosed in the first four years of life with 46% of all cases

within this age group.

Mohammed O and Aliyu H in a separate study at the Ahmadu Bello University

Teaching Hospital in north central Nigeria found Burkitt’s lymphoma to be the most

common child malignancy [24]. Their study also found retinoblastomas to be the

second most common with bone tumours very low in number. Their results also

showed higher ratio of cancers in males compared to females. Another study showed

rhabdomyosarcomas to be the most common malignant solid tumours of Nigerian

children, being diagnosed mostly under the age of 6 [25].

A study by Stefan et al in Namibia clearly shows that cases of childhood cancers in

Africa are higher than reported. The possible reasons for the lower incidence could be

related to the lack of a registry, under diagnosis and under reporting. Although the

medical infrastructure is quite well established, a vast majority of the population is

still settled in rural areas, and many do not seek the attention of western medicine

when ill. Also, a lack of experienced health care workers and concomitant infectious

diseases, which occur so commonly in the country, add to the misdiagnosis of cancer [26].

  15  

Their results showed that leukemias and retinoblastomas were most frequent cancers

encountered among children with frequency rates of 22.5% and 16.2 % respectively.

Renal tumours, soft tissue sarcomas and lymphomas followed these. Most of the

leukaemia patients, 88.4% of them had acute lymphoblastic leukaemia. Lymphomas

had a frequency rate of 12%, with a mean age of 8 years.

The mean age at diagnosis for all cancer types was 5 years and 3 months, which was

in agreement with previously available international data. Leukaemias and

lymphomas occurred in higher frequency in boys (13.6% and 8.9%, respectively)

compared to girls (8.9% and 3.1%, respectively) and retinoblastomas were also more

prevalent in boys (9.9% compared to 6.3% in girls)

Also, trends of incidence confirmed that while leukaemias are the most common

malignancy in Namibian children, retinoblastomas and lymphomas were more

common in the first 4 years.

In other studies, differences in outcome between the various ethnic groups have also

been demonstrated in South African children with Hodgkin’s lymphoma [27].

With data lacking in the most of the rest of Africa, it is almost impossible to tell

exactly what the picture looks like across the continent. Over the past 20 years the

advent of HIV has overshadowed childhood cancer in sub-Saharan Africa. However,

despite this, cancer still remains an important killer of children in Africa [28]. The HIV

epidemic on the continent has not only deprived the cancers of the needed attention

and intervention but and indeed, the infection with HIV increases the association with

malignancies [29].

  16  

2.5 TREATMENTS AND SUPPORT FOR CHILDHOOD CANCERS IN

GHANA

Ghana like other African countries does not have a well-established national cancer

control programme although the World Health Organisation (WHO) has well defined

outlines for such programmes [30].

The country has two oncology centres, one in Accra at the Korle Bu Teaching

Hospital and the other in Kumasi at Komfo Anokye Teaching Hospital. These centres

are the main referral centres for cancer cases diagnosed across the country

The country has very few trained pediatric oncologists. Other pediatricians who also

have had a lot experience in the management of childhood cancer cases have been

pivotal in the fight against childhood cancers. There are no statistics indicating how

many pediatric oncologists are active in Africa or how many nurses have been

specially trained in pediatric cancer care [7].

Diagnosis of cancer was made by bone marrow aspiration morphology (for

leukaemias) and fine needle aspiration cytology or tissue biopsy (for solid tumours).

Immunohistochemistry and molecular studies were not routinely available. Treatment

employs chemotherapy, radiotherapy and supportive treatment for most cases.

The full cost of cancer treatment is also not covered by the National Health Insurance

Scheme and is beyond the economic capabilities of most parents or caregivers. Aside

the cost, parents lose a lot of productive hours during numerous hospital admissions

and clinics visits.

Philanthropists and corporate organizations have been helpful in supporting the

paediatric oncology unit with donations.

  17  

2.6 SURVIVAL RATES OF CHILDHOOD CANCERS IN AFRICA

After accidents, cancer is the leading cause of death in children around the world [31].

In the past the survival rate of childhood cancer was very low if existed at all [7].

Presently, prognosis in the developed countries is almost excellent with survival rates

of over 80%. Sadly, this is not the same story in developing countries like Ghana,

with survival rates less than 20% [32]. While the last several decades have witnessed

tremendous advances in cure rates for childhood cancer, these improvements have not

translated to low-and- middle-income countries, where the majority of children reside [21].

Determinants of mortality and survival in children in the developing world including

African countries like Ghana differ markedly from those in the developed world.

Survival rates of children with cancer in developing countries are far lower than those

in the developed world. [27]

In a study, Stones D K et al in 2014 showed survival rates for children with cancer in

South Africa. The results demonstrate that overall survival in childhood cancer

remains low (52.1%) when compared with international data [12]. These figures are

expected to be much worse in other African countries that do not have well developed

programmes for childhood cancers like Ghana. This, in contrast to the UK which over

the past 40 years has had the overall survival rate for childhood cancer increase from

10% to nearly 90% [33]. Without official data, it will be impossible to determine what

the survival rate is and how to improve survival.

Many factors account for this. Limited resources and personnel, late presentation of

disease, co-morbid infections such as HIV and malnutrition are among the barriers

preventing improvement in survival [32]. Also there are inadequate diagnostic services,

unavailability or irregular supply and high costs of chemotherapeutic agents and

inadequate supportive care all further deepening the problems with cancer control in

poor countries like Ghana.

It has been shown that children with cancer in low-income countries commonly fail to

complete treatment for various reasons, mostly economical and cultural [34].

  18  

That not withstanding, a lot of progress can be made despite all the challenges as

about half of children with Burkitt’s lymphoma, the most common childhood

malignancy in parts of sub-Saharan Africa, are curable with three to six doses of

single-agent cyclophosphamide. This demonstrates the achievements that are possible

in even the most resource-limited settings [35].

  19  

2.7 THE WAY FORWARD

The increase in the number of cases being diagnosed means Ghana must begin to give

enough attention to childhood cancers. The Ghana Ministry of Health in 2011 set out

to draw a framework for cancer control by making the National Strategy for Cancer

Control for 2012 to 2016 [32]. The document put up a set of steps to undertake to

control all cancers in the country including childhood cancers. However, 4 years

down the line, not much has changed in the fight against cancers in children. More

commitment is needed to make strides in this regard.

In conclusion to their study, Segbefia et al recommends that the country begin to

work towards increasing public awareness as well improving capacity to diagnose and

increase access to treatment [22].

Gupta S et al proposed that meaningful declines in global childhood cancer mortality

will require moving beyond the current situation through the establishment of

National Childhood Cancer Strategies in all nations, especially low income countries

like Ghana [36]. They added that the strategies should include:

1. Financial Coverage of Childhood Cancer Treatment

2. Accreditation of Childhood Cancer Centers

3. Mandatory Childhood Cancer Reporting and Registration

4. Development of National Standards of Care

5. Creation of a National Childhood Cancer Governing Body

  20  

CHAPTER THREE

METHODOLOGY

3.0 STUDY DESIGN

This study was a descriptive study analyzing routine hospital records of the cases of

childhood cancers seen at the pediatric oncology unit of KBTH.

3.1 SAMPLING STRATEGY

Hospital records of Admission and Discharge Registers for the year were reviewed

and cases selected based on strict criteria identifying childhood cancers with

confirmed clinical and histo-pathological diagnosis from January 2014 to December

2014.

3.2 STUDY AREA

KBTH is a leading teaching hospital in Accra Ghana, located in the Ablekuma South

Sub- Metropolitan District. At the moment, the Hospital has 2,000 beds and 17

clinical and diagnostic Departments/Units. It has an average daily outpatient

attendance of 1,500 patients and about 250 patient admissions. The hospital is the

training center for medical students, nurses and doctors for postgraduate studies.

The pediatric oncology unit of the hospital was established in 2003 and is the main

center for treatment of cancer cases among children. The study population included

cases from all over country since the hospital is a center receiving referred cases from

all over the country

3.3 STUDY POPULATION

The population includes children of both sexes under 15 years who were diagnosed of

cancers seen within the period of January 1, 2014 to December 31, 2014 and were

seen and managed at the pediatric oncology unit of KBTH.

  21  

3.4 INCLUSION CRITERIA

All children aged 0–15 years with a diagnosis of a childhood cancer were

included in the study.

3.5 EXCLUSION CRITERIA

Children aged above 15 years were excluded from the study.

3.6 ETHICAL ISSUES

The research was conducted under the auspices of the Department of Community

Health, University of Ghana School of Medicine and Dentistry and the Pediatric

Oncology Unit of Korle Bu Teaching Hospital.

There were no ethical issues encountered in the undertaking of the study

3.7 DATA COLLECTION INSTRUMENTS

Data was collected from the Admissions and Discharges Registers and Pediatric

Oncology Registry forms that records each patient’s age, sex, place of residence,

histopathology diagnosis, associated morbidities, length of admission and outcome.

3.8 DATA HANDLING, ANALYSIS, AND PRESENTATION

IBM SPSS version 22.0 for Mac analysis software was used for data entry,

validation and analysis. Frequency distributions will be generated for categorical

variables. Graphical illustrations were plotted on Microsoft Excel.

  22  

CHAPTER FOUR

RESULTS

The pediatric oncology unit recorded a total of 155 cases of suspected cancer cases

from January 1st to December 31st, 2014. Out of these, 127 cases were confirmed

with histological diagnosis. 28 cases could not be confirmed either because the patient

died, absconded or sought alternative treatment elsewhere. The cases used for this

study are the 127 confirmed cases.

TABLE 4.1 A TABLE SHOWING SOME CALCULATED STATISTICS FOR

PATIENTS

TOTAL NUMBER OF CASES 127

MEAN AGE FOR ALL PATIENTS 5.73 YEARS

MEAN AGE FOR MALES 6.01 YEARS

MEAN AGE FOR FEMALES 5.4 YEARS

AGE RANGE 3 MONTHS – 14 YEARS

TABLE 4.2 A TABLE SHOWING CALCULATED INCIDENCE OF

CHILDHOOD CANCERS PER MILLION CHILDREN

CALCULATED INCIDENCE PER MILLION

CHILDREN UNDER 15

12.8 PER MILLION

CHILDREN UNDER 15

CALCULATED INCIDENCE AMONG MALES PER

MILLION MALE CHILDREN UNDER 15

14.2 PER MILLION

MALE CHILDREN

UNDER 15

CALCULATED INCIDENCE AMONG FEMALES

PER MILLION FEMALE CHILDREN UNDER 15

11 PER MILLION

FEMALE CHILDREN

UNDER 15

  23  

Most of the cases were referred from many secondary level facilities from various

regions across the country.

FIGURE 4.1 A BAR CHART SHOWING THE NUMBER OF CASES OF

CHILDHOOD CANCERS AT KBTH REFERRED FROM THE VARIOUS

REGIONS

From the chart above, it can be seen that 50.4% were referred from within the Greater

Accra Region, where KBTH is situated, 15.5% from the Eastern Region, 11.5% from

the Volta Region, 8.9% from Western Region, 7.3% from the Central Region, 2.4%

from the northern Region, 1.6% from both the Ashanti and Brong Ahafo Regions and

0.8% from the Upper East Region. No case was from the Upper West Region.

0  

10  

20  

30  

40  

50  

60  

70  

FREQUENCY  

REGIONS  

FREQUENCY  

FREQUENCY  

  24  

CANCER TYPES

Lymphoma was the most common cancer type diagnosed at the unit in 2014. A total

of 32 cases of lymphomas were recorded, representing more than a quarter of all the

cases (25.2%).

Of the lymphomas, non-Hodgkins, Hodgkin’s and other types of lymphomas

constituted 53.1% and Burkitt’s lymphomas 46.9%. This is a reverse of the trend in

the past where Burkitt’s lymphomas constituted a greater proportion of the

lymphomas diagnosed in the facility.

Leukemias were the second most common type of cancers. 25 cases were diagnosed,

making up 19.7% of all cases.

Retinoblastomas were also commonly diagnosed. 19 cases were seen and diagnosed,

constituting 14.9% of the cases.

Neproblastomas, rhabdomyosarcomas and neuroblastomas constituted 12.6%, 7.9%

and 5.4% respectively.

Other cancer types seen included hepatoblastomas (2.4%), yolk-sac tumours(1.2%),

Kaposi sarcomas (1.2%), craniopharyngiomas (1.2%) and osteosarcomas (1.2%).

Chondrosarcoma, nasopharyngeal carcinoma, spindle cell tumour, dysgerminoma of

the uterus and other rare tumours put together constituted 5.5% of the cases.

  25  

TABLE 4.3 A TABLE SHOWING THE DISTRIBUTION BY DIAGNOSIS OF

CHILDHOOD CANCERS AT KBTH

DIAGNOSIS FREQUENCY PERCENTAGE

%

CUMULATIVE

PERCENTAGE

%

LYMPHOMA

BURKITTS’

NON-HODGKIN’S

HODGKIN’S

32

15

14

3

25.2

11.8

11.0

2.4

25.2

LEUKEMIA 25 19.7 44.9

RETINOBLASTOMA 19 14.9 59.8

NEPHROBLASTOMA 16 12.6 72.4

RHABDO-

MYOSARCOMA

10 7.9 80.3

NEUROBLASTOMA 7 5.4 85.7

HEPATOBLASTOMA 3 2.4 88.1

YOLK-SAC TUMOUR 2 1.6 89.7

KAPOSI SARCOMA 2 1.6 91.3

CRANIOPHARYNGIOMA 2 1.6 92.9

OSTEOSARCOMA 2 1.6 94.5

OTHERS 7 5.5 100

TOTAL 127 100 100

  26  

SEX DISTRIBUTION OF ALL CANCER CASES

Of the 127, there was a male predominance of 55.9% of the total number of cases

with a male to female ratio of 1.3:1.

FIGURE 4.2 A PIE CHART SHOWING THE DISTRIBUTION OF

CHILDHOOD CANCERS AT KBTH BY SEX

56%  

44%  

MALES  

FEMALES  

  27  

Cancers were however more common in females from 0 to 2 years.

Table 4.4 A TABLE SHOWING THE DISTRIBUTION OF CHILDHOOD

CANCERS AT KBTH BY AGE GROUP AND SEX.

Age Group Male Female

0-2 years 12 20

3-10 years 48 27

> 10 years 11 9

Despite the general male predominance, nephroblastomas were more common in

females, with 12 out of the 16, representing 75% of the cases being recorded in

female patients.

TABLE 4.5 TABLE SHOWING SEX DISTRIBUTION OF

NEPHROBLASTOMA

SEX FREQUENCY PERCANTAGE%

MALE 4 25

FEMALE 12 75

TOTAL 16 100

  28  

TABLE 4.6 A TABLE SHOWING THE SEX DISTRIBUTION OF THE

VARIOUS CHILDHOOD CANCER TYPES DIAGNOSED AT KBTH

DIAGNOSIS MALE FEMALE TOTAL

BURKITT’S LYMPHOMA 10 5 15

OTHER LYMPHOMAS 10 7 17

LEUKEMIA 19 6 25

RETINOBLASTOMA 10 9 19

RHABDOMYOSARCOMA 7 3 10

NEPHROBLASTOMA 4 12 16

NEUROBLASTOMA 4 3 7

HEPATOBLASTOMA 2 1 3

YOLK-SAC TUMOURS 0 2 2

KAPOSI SARCOMA 2 0 2

CRANIOPHARYNGIOMA 1 1 2

OSTEOSARCOMA 1 1 2

OTHERS 1 6 7

TOTAL 71 56 127

  29  

TABLE 4.7 A TABLE SHOWING THE DISTRIBUTION OF CHILDHOOD

CANCERS AT KBTH BY AGE GROUP

AGE FREQUENCY PERCENTAGE CUMULATIVE

PERCENTAGE

<6 MONTHS 1 0.8 0.8

6-12 MONTHS 12 9.4 10.2

1-2 YEARS 19 15.0 25.2

3-4 YEARS 21 16.5 41.7

5-6 YEARS 24 18.9 60.6

7-8 YEARS 17 13.4 74.0

9-10 YEARS 13 10.2 84.3

>10 YEARS 20 15.7 100.0

TOTAL 127 100.0 100.0

From the table above, most of the cases were diagnosed between 5 and 6 years.

  30  

The pattern of incidence is generally very low under one year and a there is a steady

increase in the number of cases, which peaks at 5-6 years. Then there’s a decrease in

number of cases till age 10 after which there’s a second increase.

FIGURE 4.3 A LINE GRAPH SHOWING THE PATTERN OF INCIDENCE

OF CHILDHOOD CANCERS AT KBTH.

All individual cancer types seem to follow this trend except retinoblastomas, which

had over 90% of all cases diagnosed before the age of 5 years.

0  

5  

10  

15  

20  

25  

30  

<  6  months  

6-­‐12  months  

1-­‐2  years     3-­‐4  years   5-­‐6  years     7-­‐8  years   9-­‐10  years  >  10  years  

  31  

MOST COMMON CANCER TYPES AMONG VARIOUS AGE GROUPS

TABLE 4.8 A TABLE SHOWING THE MOST COMMON CHILDHOOD

CANCER TYPES AMONG VARIOUS AGE GROUPS AT KBTH

Age Group Most Common

Cancer Type

Frequency Percentage (%)

<6 months Non-Hodgkin’s

Lymphoma

1 100.0

6-12 months Retinoblastoma 4 33.3

1-2 years Retinoblastoma 6 31.6%

3-4 years Retinoblastoma 7 33.3

5-6 years Burkitt’s Lymphoma 6 25.0

7-8 years Non-Hodgkin’s

Lymphoma

5 29.4

9-10 years Leukemia (ALL) 4 30.8

> 10 years Leukemia (ALL) 6 30.0

  32  

Nationality And Ethnic variations: the total of 6 non-Ghanaians were among the

cases diagnosed. These include 5 Togolese and a Chadian who was born to a refugee

mother in Ghana. All the Togolese patients were of Ewe ancestry.

TABLE 4.9 A TABLE SHOWING DISTRIBUTION OF CHILDHOOD

CANCERS AT KBTH BY NATIONALITY

NATIONALITY FREQUENCY PERCENTAGE

GHANAIAN 121 95.3

NON-GHANAIAN 6 4.7

TOTAL 127 100.0

Of the Ghanaian patients, 55 of them, making 43.7% were of Akan descent, those of

Ewe ancestry constituted 27.8% and Ga descent (11.9%). The Northern tribes made

up of Dagombas, Mamprusis, Gonjas, Kokomba and Wala tribes constituted 6.3% and

Nzema (0.01%).

  33  

FIGURE 4.4 A DOUGHNUT SHOWING THE DISTRIBUTION OF

CHILDHOOD CANCER CASES AT KBTH BY ETHNIC BACKGROUND.

44%  

28%  

12%  

6%  1%  

9%  

Akan  

Ewe  

Ga  

Northen  Tribes    

Nzema  

Others    

  34  

GEOGRAPHICAL ANALYSIS:

Most patients (89) were Urban and peri-urban dwellers 70.1% and 38 (29.9%) were

from rural communities.

FIGURE 4.5 A BAR CHART SHOWING THE RURAL-URBAN

DISTRIBUTION OF CHILDHOOD CANCER CASES AT KBTH

0   10   20   30   40   50   60   70   80   90  

urban  

rural  

FREQUENCY  

  35  

LYMPHOMAS

47% of all cases of lymphoma were Burkitt’s lymphoma, 44% were non-Hodgkin’s

lymphoma and 9% were Hodgkin’s lymphoma.

FIGURE 4.6 A PIE CHART SHOWING THE TYPES OF LYMPHOMAS

DIAGNOSED

The peak age of diagnosis of Burkitt’s was at 5-6years while the age of diagnosis of

other lymphoma types peaked at 7-8 years.

Sex Distribution: 62.5% of all lymphoma cases were diagnosed in male patients and

37.5% were in females.

47%  

44%  

9%  

BURKITT'S  

NON-­‐HODGKIN'S  

HODGKIN'S  

  36  

Ethnic variation: 50% of all cases were in patients with Akan ancestry, 25% in

pateints with Ewe ancestry. 9% had Ga backgrounds, 3% were from northern tribe

ancestry and 13% from other tribes.

FIGURE 4.7 A BAR CHART SHOWING THE ANCESTRAL BACKGROUND

OF PATIENTS DIAGNOSED WITH LYMPHOMAS

66.7% of Burkitt’s lymphoma cases were diagnosed in patients with Akan ethnicity.

13.3% of patients had Ewe backgrounds and 6.7% of patients were Gas.

In patients with other type of lymphomas, 35.2% were Akan, 29.4% were Ewe and

11.8% were Ga.

0  

5  

10  

15  

20  

25  

30  

35  

40  

45  

50  

PERCENTAGE  %  

  37  

Geographical analysis:

Majority of Burkitt’s lymphoma patients were residents of urban and peri-urban

communities.

67% of all cases were from these communities. 33% of the patients were from rural

communities.

FIGURE 4.8 A PIE CHART SHOWING THE RURAL-URBAN

RESIDENTIAL DISTRIBUTION OF PATIENTS WITH BURKITT’S

LYMPHOMA AT KBTH

67%  

33%  

urban  and  peri-­‐urban  

rural  

  38  

52% of patients with the other types of lymphomas (Hodgkin’s and non-Hodgkin’s)

were from urban and peri-urban communities while 48% were from rural

communities.

FIGURE 4.9 A PIE CHART SHOWING THE RURAL-URBAN

RESIDENTIAL DISTRIBUTION OF PATIENTS WITH OTHER TYPES OF

LYMPHOMA AT KBTH

53%  

47%   URBAN  AND  PERI-­‐URBAN  

RURAL  

  39  

LEUKEMIAS

Leukemias were the second highest cancers of children from the study.

25 cases were diagnosed representing 19.7% of all cases.

15 out of the 25 cases of leukemia diagnosed were ALL. This represented 60% of all

leukemia cases, making it the most common leukemia type diagnosed at the facility.

9 cases (36%) were AML.

Only one case of the chronic type of leukemia was diagnosed (4%)

FIGURE 4.10 A PIE CHART SHOWING THE TYPES OF LEUKEMIA

DIAGNOSED

No case was diagnosed under the age of 1 and the highest numbers of cases were

diagnosed in patients below 10 years (76%).

Sex Distribution: The leukemias were more common in male patients. 76% of

patients were and 24% were females.

60%  

36%  

4%  

AML  

ALL  

CML  

  40  

Ethnic Variation: most patients diagnosed with leukemia were of Akan ancestry

(44%) followed by Ewe (28%), Ga ancestry (12%), Northern tribes (4%) and other

tribes (12%)

FIGURE 4.11 A BAR CHART SHOWING THE ANCESTRY OF PATIENTS

DIAGNOSED WITH LEUKEMIA

0  

5  

10  

15  

20  

25  

30  

35  

40  

45  

AKAN  EWE  

GA  NORTHERN  TRIBE   OTHERS  

44  

28  

12  

4  12  

PERCENTAGE  %  

  41  

Geographical analysis:

22 out of the 25 (88%) patients diagnosed with leukemias were residents of urban and

peri-urban communities while 12% were from rural communities.

FIGURE 4.12 A PIE CHART SHOWING THE RURAL-URBAN

RESIDENTIAL DISTRIBUTION OF PATIENTS WITH LEUKEMIA AT

KBTH

88%  

12%  

URBAN  AND  PERI-­‐URBAN   RURAL  

  42  

CHAPTER FIVE

DISCUSSION

5.0 INTRODUCTION

A total of 127 cases of childhood cancers were diagnosed in 2014. This figure is

consistent with results from a 4-year study by Segbefia et al in the same health

facility, which showed an annual average of 124 cases a year [22]. This figure is

however much higher than that found by Welbeck et al in their study from 1992 to

1995 [2]. This is also much higher than figures from Kano, Nigeria where 438 cases of

childhood cancers were diagnosed over a 10-year period, averaging 43.8 cases a year [6].

The youngest patient was a 3-month-old baby diagnosed with a lymphoma and the

eldest a 14-year old girl with craniopharyngioma. A six-week old infant was the

youngest patient in a previous study in the same hospital [22]. Most of the cases were

diagnosed below 10 years and peaked at between 5 and 6 years. The mean age of all

patients was 5.7 years. The average age of male patients was 6.01 years, which is

higher than the average of all patients. Average age for female patients was 5.4 years,

lower than that of male patients.

5.1 INCIDENCE PER MILLION CHILDREN

The calculated incidence per million children was 12.8 per million children. This was

lower than rates of other low-income countries like 71.2 per million children recorded

in Nigeria, 77.4 per million children from Mali and 64.4 per million children in India

This rate was even lower when compared with Denmark, UK, USA, Sweden and

other high-income counties who have an average of 130 cases of childhood cancers

per million children [21].

The lower rates could be as a result of under diagnosis of the cases of cancer because

of lack of personnel, logistics and diagnostic capacity of health institutions.

  43  

5.2 SEX DISTRIBUTION OF PATIENTS

Most of the patients were male patients representing 55.9% of all patients. A

percentage of 56.6% was the result of a previous study in the same health facility [22].

The male to female ratio of 1.3: 1 from this previous remains unchanged when

compared with the results of this study. This ratio of 1.3:1 is similar to that found

after a study in Kano in Nigeria [6] and does not show much variation from results

from Ahmadu Bello University Teaching Hospital in Nigeria, where the male to

female ratio was 1.5:1 [24].

Despite the male preponderance, nephroblastomas were more common among

females. 75% of the cases seen were in female patients. Lymphomas, leukemias,

rhabdomyosarcomas were more common in males.

Burkitt’s lymphoma was twice more common in male patients than in female patients,

consistent with results of published work by Orem at al. [37].

Retinoblastomas showed an even distribution between both genders.

5.3 MOST COMMON CANCER TYPES DIAGNOSED

Lymphomas were the most common type of cancers diagnosed, making up 32% of all

diagnoses. This is consistent with studies in the same hospital [22] about 4 years ago

and in Zaria, Nigeria [24] where lymphomas were the most common type of cancers in

children. This is however different from results from Windhoek, Namibia [28] where

leukemias were most common, and lymphomas were fifth most common constituting

only 12% of all cases. The differences could be explained by climate difference

between West Africa and Southern Africa, and relative difference in incidence of

malaria, which has been found to be associated with the development of endemic

Burkitt’s lymphoma.

The results also showed a decrease in the proportion of all cancers and lymphomas

that were Burkitt’s lymphoma. Burkitt’s lymphomas constituted 15% of all childhood

cancer cases and other types of lymphomas (Hodgkin’s and non-Hodgkin’s) made up

17%. This showed that Burkitt’s lymphoma made up 46.8% of all lymphomas, much

lower than what Segbefia et al found [22] from 2008 to 2011. Their study showed that

Burkitt’s lymphoma made up over 70% of all lymphomas diagnosed. This could be a

demonstration of a decrease in the number of endemic Burkitt’s lymphomas, which

  44  

are associated with recurrent malaria. This could be as a result of national gains in

malaria control by proper implementation of control strategies such as the use of

insecticide treated nets etc. This could also be due to a general decline in the

incidence of Burkitt’s lymphoma as seen parts of southern Nigeria in Ibadan and

Lagos [38,39].

Leukemias were next common cancers (19.7%) and retinoblastomas (14.9%),

nephroblastomas (12.6%). This study shows slight increase in the number of leukemia

cases diagnosed in a year, as 25 cases were diagnosed in 2014 compared to 23 from

results of study by Segbefia et al. This represented 19.7% of all cases compared with

18.8 % from previous study in the same facility from 2008 to 2011 [22].

Acute forms of leukemia were the most common form leukemia diagnosed. ALL and

AML made up 60% and 36% respectively, and a combined 96% of all cases of

leukemia. This is consistent with previous study by Segbefia et al where ALL was

found to be the most common type with almost 70% of all cases being of this type [22].

However, results from Kano, Nigeria showed AML to be the most common type of

leukemia diagnosed in a 10-year study at the Aminu Kano Teaching Hospital

(AKTH) [6].

A large proportion (89.4%) of the cases of retinoblastoma were diagnosed in patients

below the age of 5 years. This is in agreement with results of 10-year study from

Kano where 91% of all cases of retinoblastoma were diagnosed below 5 years [6].

Also, 83.3% of all cases diagnosed in KBTH between 2008 and 2011 were under the

age of 5.[22]. Also, results from a study in Namibia retinoblastomas were more

common in the first 4 years.

Two cases of Kaposi sarcoma were diagnosed and both patients were HIV-positive.

No case of Kaposi was documented in previous study in the same health facility. This

represented 1.6% of all cancer cases diagnosed in 2014, lower than the 5% stated

from national data from South Africa [40] and 5.7% in Namibia [41]. The prevalence

rate of HIV, the underlying cause of Kaposi sarcoma is also lower in Ghana than in

these countries.

  45  

5.4 AGE CHARACTERISTICS OF PATIENTS

Most of the patients were aged 10 years and below (84.3%). Only 20 patients,

representing 15.7% of all cases were aged above 10 years. Most of the cases were

diagnosed between age 5 and 6. This is consistent with previous work done in the

same facility where 89% of the cases were 10 years and below [22]

The most common cancer type for patients between 1 and 4 years was

retinoblastomas. Burkitt’s lymphoma was the most common cancer for patients

between age 5 and 6. Between age 7 and 8, non-Hodgkin’s lymphoma was the most

common type diagnosed. Leukemias were the most common for patients aged 9 and

above.

5.5 ETHNIC BACKGROUND OF PATIENTS

Majority of the patients were of Akan ancestry. They represented 44% of all patients.

Akan is the most common ethnic group in Ghana, making up about 47.5% of all

Ghanaians, and this could explain why most patients were Akan due to the mere

number of Akans in the country. Of those with Akan ancestry, the Fante subtribe

constituted the highest proportion making up 41.8% of all those of Akan ancestry and

18.2% of the total number of cases. This is despite the Ashantis being the most

common Akan sub-tribe in the country.

Those of the Ewe tribe constituted 28% of all cases and northern tribes made up only

6% of all cases despite being the second largest tribe in Ghana.

Leukemia and Burkitt’s lymphoma were the most common cancer types diagnosed

among patients of Akan ancestry while retinoblastoma was the most common type

among those of Ewe ancestry. Patients of the Ga tribe had nephroblastoma as the most

common cancer type.

5.6 GEOGRAPHICAL ANALYSIS OF CASES

89 out of the 127 patients, constituting 70.1% of all cases were residents of urban and

peri-urban communities. 29.9% of patients were from rural communities. This

disparity could be under-diagnosis and prompt referral from health facilities in rural

communities as theses facilities lack well-trained staff in areas of recognizing

symptoms of childhood cancers.

  46  

Another possible explanation is the fact that many rural folk would rather resort to

traditional ways of treatment than travel many miles away from home to access care

in tertiary health institutions like KBTH.

That not withstanding the relationship between industrialization and development of

cancers in children has been established in many counties. Change in environmental

factors such as exposure to radiations and chemicals that predispose mothers to

having children with cancers are higher in many urban communities across the world.

This is one of the explanations for the differences in incidence of childhood cancers in

low-income countries and highly industrialized high-income countries [21].

67% of all cases of Burkitt’s lymphoma were from urban and peri-urban

communities. This is different from the results of the other lymphoma types which

showed even distribution between rural and urban communities. 52% of these patients

were from urban and peri-urban communities and 48% from rural communities. This

could be due to higher incidence of recurrent malaria infection, which is associated

with Burkitt’s lymphoma from poor drainage systems and generally bad hygienic

conditions in urban and peri-urban communities.

Leukemia was also more in residents of urban communities. Only 12% of patients

with leukemia were from rural communities. This could be explained by two theories

of leukemogenesis. The population- mixing hypothesis [42] and the delayed-infection

hypothesis [43] are both infection-based theories, which propose that the peak

incidence of leukemias in industrialized communities is due to an early infectious

insulation. This predisposes the immune system of individuals susceptible, to

abnormal or pathologic responses after subsequent or delayed exposure to common

infections at an age where there is increased lymphoid cell proliferation [42, 43].

Environmental factors have also been implicated.

Retinoblastomas and other cancers however showed an almost even distribution

between rural and urban dwellers.

  47  

Despite the sure cases of environmental factor differences between rural and urban

communities, under diagnosis and prompt referral as well as under reporting in rural

communities remain a big issue in really determining the more accurate differences in

incidence between urban and rural communities across the country.

Also, majority of the cases were referred from within the Greater Accra region, home

of the capital Accra. The landscape of the Greater Accra region is generally an

urbanized region, which is predominantly a low-lying undulating coastal plain with

heights scarcely reaching more than 250 feet above sea level. The vegetation is

predominantly of coastal savannah grassland type with pockets of thickets of forests

along the stream courses and mangrove and swampy vegetation along the coastal

lagoons.

5.7 REGIONAL REFERAL VARIATIONS

Most of the cases were referred from within the Greater Accra region, where KBTH is

located. The nearness of the facility to other health facilities makes it the major point

for referral of such cases. It is also convenient for parents and patients to seek care at

the hospital as it is closer to home and parents can still manage to continue work and

take care of other responsibilities while still accessing care at the facility.

The Eastern and Volta regions, which recorded the next highest number of referrals,

are also close to the Greater Accra region.

The least number of cases were referred from Upper East region and no case from

referred from the Upper West region. These regions are very far north of the country,

and it takes over 18 hours to commute to Accra by road. There is therefore a lot of

inconvenience in attending KBTH for most parents.

Also, there are teaching hospitals in Tamale in the Northern region of the country and

in Kumasi in the Ashanti region as well as Cape Coast in the Central region. These

points will serve as referral points for cases of childhood cancers diagnosed in these

regions and their surrounding regions.

Although these facilities do not have well-established paediatric oncology units, they

will be more convenient points of care for parents and patients than commuting to

Accra for care.

  48  

CHAPTER SIX

RECOMMENDATIONS

6.0 INTRODUCTION

Childhood cancer is not yet a major problem for the Ghana Health Sector as malaria

and other infectious diseases remain high on the national agenda. However the right

amount of attention and recourses should be allocated to this area to prevent it from

becoming a national headache in years to come.

6.1 NEED FOR NATIONAL CANCER REGISTRY

The lack of a national population-based registry to monitor the trends in cancer

incidence has left only hospital-based information as the only source of information.

There is a need for the development of a national registry for proper planning of

national programmes to combat childhood cancers and for research work.

6.2 PUBLIC EDUCATION AND NATIONAL AWARENESS

Also, there is a need for raising awareness on childhood cancers through public

education programmes and having workshops for health workers in at the primary and

secondary levels to be able to identify and promptly refer for proper management.

The should be a national childhood cancer awareness day to debunk myths and

superstitions about cancers, teach general public about common presenting symptoms

and the need for immediate reporting to health facility for prompt and proper

management.

6.3 IMPROVING ACCESS TO PROPER HEALTHCARE

There is the need to increase access to care for patients with childhood cancers by

having small pediatric oncology units in the ten regional hospitals in the country. This

will require training of nurses who can have special training in basic administration of

chemotherapy agents and dealing with it’s complications. This will reduce the burden

on tertiary institutions like KBTH, and also reduce the cost of travel and loss of time

from work for most parents who leave their homes several miles away to access care

for their children in Accra.

  49  

6.4 REDUCING COST OF CANCER TREATMENT

There is a need for government commitment to controlling cancer among children and

reducing burden of cost of treatment on parents by subsidizing the cost of treatment

and ultimately introducing care for children with cancers under the National Health

Insurance Scheme (NHIS).

6.5 CALL FOR RESEARCH INTO CHILDHOOD CANCERS

There is a need for more research into childhood cancers. Identification of local risk

factors, ways of improving diagnosis and management should be prioritized.

  50  

CHAPTER SEVEN

CONCLUSION

Childhood cancer cases at KBTH have remained at the same level over the past 5

years. A total of 127 cases were diagnosed in 2014 with an incidence of 12.8 per

million children.

The cancer cases were more common in male children with a male to female ratio of

1.3:1.

Lymphomas were the most common type of cancer diagnosed. However the incidence

of Burkitt’s lymphoma has seen a decline over the years.

Leukemia, retinoblastoma and nephroblastoma were the next most common cancer

types.

Most patients were residents of urban and peri-urban communities and most cases

were from within the Greater Accra region

There is a need for more attention towards childhood cancers in Ghana as mortality is

very high despite these cancers being highly curable.

Unless there’s a highly structured cancer control programme, which has, population

based registry at the core, the nation will continue to lose many children to the cancer

  51  

CHAPTER EIGHT

REFERENCES 1. Stefan Dc., Patterns Of Distribution Of Childhood Cancer In Africa, Journal

Of Tropical Pediatrics, February 2015

2. Welbeck J, Hesse A, Pattern Of Childhood Malignancy In Korle Bu Teaching

Hospital, Ghana, West Afr J Med. Apr-Jun 1998; 17(2): 81-84

3. Tomatis L: Overview Of Perinatal And Multigeneration Carcinogenesis. Iarc

Sci Publ, 1992; 96:1-15.

4. Williams AO. Tumours of childhood in Ibadan, Nigeria. Cancer 1975; 36:370-

378.

5. Stefan D C. Epidemiology Of Childhood Cancer And The Saccsg Tumour

Registry. Continuing Medical Education 2010; 28(7): 317-319.

6. Ochicha O, Aisha K G, Dalhatu G, Pediatric malignancies in Kano, Northern

Nigeria, World J Pediatr 2012;8(3): 235-239

7. Stefan DC, Childhood Cancer In Africa; Past, Present And Future, J. Afr.

Cancer (2014) 6:127-128

8. Brown B., Bamigboye E., Sodeinde O., Causes Of Death In Childhood Cancer

At The Department Of Paediatrics, University College Hospital, Ibadan. Afr J

Med Med Sci 2008; 37(1): 7-13

9. Schilling FH, Spix C, Berthold F, Erttmann R, Fehse N, Hero B, Klein G,

Sander J, Schwarz K, Treuner J, Zorn U, Michaelis J, Neuroblastoma

screening at one year of age. N Engl J Med, 2002; 346: 1047–1053

10. Stack M, Walsh Pm, Comber H, Ryan Ca, O'lorcain P. Childhood Cancer In

Ireland: A Population-Based Study. Arch Dis Child. 2007; 92: 890-897.

PubMed | Google Scholar

11. Hammond D. Management Of Childhood Cancer. Ca Cancer J Clin. 1990;

40(6): 325-326

12. Stones D K, De Bruin G P, Esterhuizen T M, Stefan D C, Childhood Cancer

Cases Survival Rates In Two South African Units, S Afr Med J 2014; 104(7):

501-504. Doi: 10.7196/Samj.7882

  52  

13. Ross J A., Olshan A. F., Pediatric Cancer In The United States: The

Children’s Oncology Group Epidemiology Research Program, Cancer

Epidemiology, Biomarkers & Prevention, October 2004; 13(10): 1552 – 1554

14. McKinney P, Feltbower R, Parslow R, Lewis I, Glaser A, Kinsey S. Patterns

of childhood cancer by ethnic group in Bradford, UK 1974–1997. European

Journal of Cancer. 2003;39(1):92-97.

15. Ries LAG, Smith MA, Gurney JG, Linet M, Tamra T, Young JL, Bunin GR,

Cancer Incidence and Survival Among Children and Adolescents: United

States SEER Program 1975-1995. Bethesda, MD: National Cancer Instutite;

1999 (NIH Publication No.99-4649)

16. Ferlay J et al. GLOBOCAN 2002: Cancer incidence, mortality and prevalence

worldwide. IARC Cancer Base, 2004; 5(2). Lyon, IARCPress

17. Http://Seer.Cancer.Gov/Iccc/Iccc-Who2008.Html ICCC Recode Icd-O-3/Who

2008 Table, Accessed 20th April 2015.

18. Mbulaiteye S, Bhatia K, Adebamowo C, Sasco A., HIV And Cancer In Africa:

Mutual Collaboration Between HIV And Cancer Programs May Provide

Timely Research And Public Health Data. Infect Agents Cancer. 2011;

6(1):16

19. Http:/Acco.Org/Information/Aboutchildhoodcancer/Childhoodca

Ncerstatistics.Aspx. Accessed 12th April 2015

20. Http://Seer.Cancer.Gov/Csr/1975_2004/Results_Merged/Sect_29

_Childhood_Cancer_Iccc.Pdf Accessed 20th April 2015.

21. Howard S C, Metzger L M, Wilimas A J, Quintana Y, Pui C, Robison L L,

Ribeiro C R, Childhood Cancer Epidemiology in Low-Income Countries,

Cancer 2008; 112:461–472.

22. Segbefia C., Renner L, Dei-Adomakoh Y, Welbeck J, Changing Pattern Of

Childhood Cancers At Korle Bu Teaching Hospital, Accra, Postgraduate

Medical Journal Of Ghana, September 2013; 2(2): 65-67

23. Gyasi R. K., Tettey Y., Childhood Deaths From Malignant Neoplasms In

Accra, Ghana Medical Journal, June 2007; 41(2): 78-81

24. Mohammed A, Aliyu H O., Childhood cancers in a referral hospital in

northern Nigeria, Indian J Med Paediatr Oncol. 2009 Jul-Sep; 30(3): 95–98

  53  

25. Na’anlep M. T, Godwin O. E, Nanfwang A. M, Mafala B. M, Uba A. F.,

Paediatric solid tumours in Nigerian children: A changing pattern? African

Journal of Paediatric Surgery, 2009; 6 (1): 7-10

26. Stefan D, Stones D, Dippenaar A, Kidd M, Ethnicity And Characteristics Of

Hodgkin Lymphoma In Children. Pediatric Blood Cancer 2009; 52(2): 182-

185.

27. WHO, National Cancer Control Programmes: Policies And Managerial

Guidelines, 2nd Edn. Geneva: World Health Organization, 2002

28. Ribeiro R, Pui C. Saving The Children--Improving Childhood Cancer

Treatment In Developing Countries. N Engl J Med. 2005; 352(21): 2158-

2160.

29. Safai B, Diaz B, Schwartz J. Malignant Neoplasms Associated With Human

Immunodeficiency Virus Infection. Ca Cancer J Clin. 1992; 42(2): 74-95.

30. Bleyer W. The Impact Of Childhood Cancer On The United States And The

World, Ca Cancer J Clin. 1990; 40(6): 355- 367.

31. National Strategy For Cancer Control in Ghana, Ministry of Health, June

2011, Accra.

32. Gatta G, Botta L, Rossi S, Aareleid, T, Bielska-Lasota, M., Clavel, J.,

Dimitrova, N., Jakab, Z, Kaatsch, P., Lacour, B., Mallone, S., Marcos-

Gragera, R., Minicozzi, P., Sánchez-Pérez, M., Sant, M., Santaquilani, M.,

Stiller, C, Tavilla A, Trama A, Visser O, Peris-Bonet R, Childhood Cancer

Survival In Europe 1999-2007: Results Of Eurocare-5 – A Population-Based

Study. Lancet Oncol 2014; 15(1): 35-47

33. Arora R, Eden T, Pizer B. The Problem Of Treatment Abandonment In

Children From Developing Countries With Cancer. Pediatr Blood Cancer

2007; 49(7): 941-946

34. Harif M, Barsaoui S, Benchekroun S, Bouhas R, Doumbe P, Khattab M,

Ladjay Y, Moreira C, Mseifer-Alaoui F, Patte C, Rakotonirina G, Raphael M,

Raquin M, Lemerle J, Treatment of B-cell lymphoma with LMB modified

protocols in Africa - Report of the French-African Pediatric Oncology Group

(GFAOP). Pediatr Blood Cancer, 2008; 50: 1138–1142.

35. Gupta S, Rivera-Luna R, Ribeiro RC, Howard SC, Pediatric Oncology as the

Next Global Child Health Priority: The Need for National Childhood Cancer

Strategies in Low- and Middle-Income Countries. 2014; PLoS Med 11(6):

  54  

e1001656. doi:10.1371/journal.pmed.1001656

36. Orem J, Mbidde EK, Lambert B, Sanjose S, Weiderpass E., Burkitt’s

lymphoma in Africa, a review of epidemiology and etiology. Afr Health Sci

2007;7:166-175

37. Ojesina AI, Akang EE, Ojemakinde KO., Decline in Burkitt's lymphoma

relative to other childhood malignancies in Ibadan, Nigeria. Ann Trop Paediatr

2002;22:159-163

38. Tijani SO, Elesha SO, Banjo AA., Morphological pattern of pediatric solid

cancer in Lagos, Nigeria. West Afr J Med 1995; 14:174-180.

39. Stefan DC, Wessels G, Poole J., “Infection with human immunodeficiency

virus-1 (HIV) among children with cancer in South Africa,” Pediatric Blood &

Cancer, 2011; 56 (1); 77–79.

40. Baadjies B, Stefan DC, “A survey of paediatric cancers presenting to

Windhoek Central Hospital, Namibia from 2003 to 2010: a retrospective

study,” SAMJ.

41. Kinlen L., Infections and immune factors in cancer: the role of epidemiology.

Oncogene. 2004; 23:6341–6348.

42. Greaves M., Infection immune responses and the aetiology of childhood

leukaemia. Nat Rev Cancer. 2006; 6:193–203.

  55  

CHAPTER NINE

APPENDIX PEDIATRIC ONCOLOGY REGISTRY

DATE OF ADMISSION: …………………..

DATE OF FIRST DISCHARGE: ……

DEMOGRAPHICS

PATIENTS FIRST NAME: ……………………………………..

PATIENTS LAST NAME : ……………………………………..

PATIENTS ADDITIONAL LAST NAMES: ……………………………………..

BIRTHDAY: DATE ……………… MONTH…… YEAR………..

AGE : ……………………………………..

PATIENTS’S CHART ID : ……………………………………..

GENDER (PLEASE CIRCLE) : MALE FEMALE

TRIBE (ETHNICITY) : ……………………………………..

PHONE NUMBER: ……………………………………..

MOBILE PHNE NUMBER: ……………………………………..

ADDRESS: ……………………………………..

NEIGHBOURHOOD: ……………………………………..

CITY: ……………………………………..

TRAVEL TIME (HOURS) FOR FAMILY TO COMMUTE TO KORLE BU………

FATHER’S NAME……………………………………..

FATHER’S PHONE………………………………………

FATHER’S OCCUPATION……………………………

MOTHER’S NAME: ……………………………………..

MOTHER’S NAME: ……………………………………..

MOTHERS OCCUPATION: ……………………………………..

NUMBER OF SIBLINGS LIVING AT HOME: ……………………………………..

ITN (PLEASE CIRCLE) : YES OR NO

NHIS (PLEASE CIRCLE) : YES OR NO

Travel TIME TO KBTH FROM HOME ……….. HOURS

IF PLAN IS TO RECEIVE CARE AT SATELITE SITE, GIVE SITE NAME:…………

  56  

CURRENT COMPLAINTS

PRIMARY COMPLANIT(S) AT TIME OF INITIAL PRESENTATION TO KORLE

BU……………………………………………………………………………………..

DURATION FROM FIRST SYMPTOM TO CONSULTATION AT KBTH……….

PHYSICAL EXAM/LABS AT INITIAL KBTH VISIT

GENERAL: PLEASE CIRCLE HEALTHY OR ILL- LOOKING

HEIGHT …………….CM WEIGHT ………………KG

NUTRITIONAL STATUS: POOR/ MODERATE/ GOOD

PERTINENT FINDINGS ON INITIAL PHYSICAL EXAM ………………………………

………………………………………………………………………………………………..

………………………………………………………………………………………………..

DESCRIBE VISIBLE/ PALPABLE LOCATION AND OF MASSES (EG: 3X3 PALPABLE

MASS IN RUQ ABDOMEN)

…………………………………………………………………………………………………

…………………………………………………………………………………..

LABS

RETRO-SCREEN (PLEASE CIRCLE) : REACTIVE NON-REACTIVE NOT TESTED

INITIAL WBS………… ABS NEUTROPHIL COUNT…… ABS LYMPHOCYTE COUNT…..

INITIAL HEMOGLOBIN……… INITIAL PLATELETS……….

INITIAL URIC ACID………… INITIAL LDH ……. INITIAL CHEMISTRIES ……………

BONE MARROW DATE MARROW DONE………………

RESULTS ………………………………………………….

FNAC DATE FNAC DONE…………………

RESULTS…………………………………………

CSF EXAM DATE LUMBAR PUNCTURE DONE…………………

RESULTS…………………………………………..

DIAGNOSTIC IMAGING DATE OF IMAGING……………………..

MODALITY: PLEASE CIRCLE X-RAY, US, CY, MRI

  57  

PRIMARY FINDING…………………….

DIAGNOSTIC IMAGING DATE OF IMAGING……………………..

MODALITY: PLEASE CIRCLE X-RAY, US, CY, MRI

PRIMARY FINDING…………………….

DIAGNOSTIC IMAGING DATE OF IMAGING……………………..

MODALITY: PLEASE CIRCLE X-RAY, US, CY, MRI

PRIMARY FINDING…………………….

PROCEDURE DATE OF PROCEDURE……………….

SURGICAL DETAILS:………………..

PATHOLOGY RESULTS: ………………….

FINAL HISTOLOGY REPORT:……………………………..

DIAGNOSIS DISEASE (PLEASE CIRCLE DISEASE BASED ON OPTIONS BELOW)

BENIGN

• LEUKEMIA – ALL, AML, ACUTE PROMYELOCYTIC ANEMIA, CLL, CML,

MYELODYSPLASIA, MYELOPROLIFERATIVE SYNDROME

• LYMPHOMA – HODGKIN’S LYMPHOMA, LYMPHOMA NOS, NON-HODGKIN’S

LYMPHOMA (NOT INCLUDING BURKITT’S LYMPHOMA), BURKITT’S

LYMPHOMA

• SOLID TUMOUR – CNS, CARCINOMA, EWINGS, GI STROMAL TUMOUR,

GERM CELL TUMOUR (NON-CNS), HEMANGIOMA, HEPATOBLASTOMA,

HEPATOCELLULAR CARCINOMA, HISTIOCYTIC TUMOUR,

MEDULLOBLASTOMA, NEUROBLASTOMA, NON-WILM’S RENAL CANCER,

NON-RHABDOMYOSARCOMA, OSTEOSARCOMA, PAROTID CARCINOMA,

RETINOBLASTOMA,

RHABDOMYOSARCOMA, SKIN CANCER, THYROID CARCINOMA, WILM’S

TUMOUR

• UNSPECIFIED MALIGNANT NEOPLASM

• OTHER…………………………………………..

DATE OF DIAGNOSIS……………..

PLEASES CIRCLE: CLINICAL OR PATHOLOGICAL DIAGNOSIS

  58  

IF CLINICAL, GIVE DATE OF DEFINITIVE DIAGNOSIS: ……………………..

CLASSIFICATION AND STAGING: ………………………………………………..

TREATMENT (PLEASE CIRCLE FROM LIST)

CURATIVE INTENT, PALLIATIVE INTENT, TREATMENT REFUSAL

PROTOCOL SELECTED………………………..

DATE OF TREATMENT START:………………..

PLEASE ENSURE A COPY OF THE CHEMOTHERAPY PROTOCOL IS IN PATIENT’S

ONCOLOGY CHART

FOLLOW UP INVESTIGATIONS

BONE MARROW

DATE:………………. DATE:…………………… DATE:……………..

FNAC

DATE:………………. DATE:…………………… DATE:……………..

CSF

DATE:………………. DATE:…………………… DATE:……………..

PHYSICAL EXAM

DATE:………………. DATE:…………………… DATE:……………..

IMAGING

DATE/MODALITY:……… DATE/MODALITY:……… DATE/MODALITY:……………..

PLEASE ENSURE ALL FOLLOW-UP REPORTS ARE IN PATIENT’S ONCOLOGY CHART

RESPONSE TO TREATMENT (PLEASE CIRCLE): COMPLETE PARTIAL PROGRESSIVE

DISEASE

TREATMENT COMPLETION DATE:…………………

IF RELAPSED, DATE OF RELAPSE:………………………

SITE OF RELAPSE: LUNG, LIVER, BONE MARROW, CNS, KIDNEY, SPLEEN,

LYMPH NODES, TESTICULAR, MEDIASTINAL, OTHER…………………………

RELAPSE DECISION: TREAT VS PALLIATIVE VS NO INTENTION

IF TREATING RELAPSE, PROTOCOL………………………….

RESPONSE TO RELAPSE: COMPLETE/PARTIAL/NONE

  59  

OUTCOME

DATE…………………………..

(PLEASE CIRCLE SELCTION FROM LIST AND COMPLTE CATEGORY PER SELECTION)

ALIVE, EXPIRED, ABANDONED, LOST TO FOLLOW UP, REFUSED

IF ALIVE, THEN NEXT FOLLOW-UP:……………………..

FOLLOW-UP DATE:…………………………….

FOLLOW-UP DATE:…………………………….

FOLLOW-UP DATE:…………………………….

FOLLOW-UP DATE:…………………………….

IF EXPIRED, THEN RECORD THE FOLLOWING DATA POINTS

1) CAUSE OF DEATH (CIRCLE OPTION BELOW): PROGRESSIVE DISEASE,

TOXICITY FROM TREATMENT, UNRELATED TO DISEASE OR TREATMENT,

INFECTION, HEMORRHAGE, SEPSIS, OTHER (DESCRIBE)…………………….

2) DIRECT CAUSE OF DEATH………………………………………

3) PLACE OF DEATH:…………………………………………

4) COMMENTS:………………………………………………

5) SITE OF INFECTION (IF PRESENT):………………………..

6) INFECTING ORGANISM:……………………………..

IF ABANDONED, RECOED THE FOLLOWING DATA POINTS

1) REASON FOR ABANDONMENT (CIRCLE OPTION BELOW): LACK OF MONEY,

HERBAL REMEDY, DEPENDING ON HEALING THROUGH FAITH,

MISTRUST OF THE HOSPITAL, TOO MUCH TIME AWAY FROM WORK,

TOO FAR TO TRAVEL TO CLINIC, COMPETING NEEDS OF OTHER

FAMILY MEMBERS, SOCIO-ECONOMIC, ALTERNATIVE THERAPY,

CULTURAL/RELIGIOUS, OTHER, NO REASON

2) REASON FOR ABANDONMENT (OTHER) : …………………………………….

3) SEARCH CONDUCTED FOR PATIENT: NO DATA, YES, NO

4) ABANDONMENT REASON COMMENTS:………………………………………

5) ATTEMTED CONTACTS (KEEP LIST OF DATE, TYPE, PERSON CONTACTED,

PERSON WHO CONTACTED)

  60  

DATE TYPE OF

CONTACT

(PHONE OR

VISIT)

PERSON

WHO

CONTACTED

PERSONAL

CONTACTED

PLAN

IF LOST TO FOLLOW-UP, RECORD FOLLOWING DATA POINTS

1) PLEASE CIRCLE ONE OF THE FOLLOWING OPTIONS: DID NOT RETURN TO

CLINIC OR TRANSFERRED TO ANOTHER ONCOLOGIST

2) LOST TO FOLLOW-UP COMMENTS:……………………………………………

REFERRAL/TREATMENT:

HOME COMMENT:

PROVISIONAL DIAGNOSIS:

INITIAL CHEMISTRIES DATE:……………..

SODUIM…….. GOT(AST):…………. BILIRUBIN TOTAL:……………….

POTASSUIM:……… GPT(ALT):………… BILIRUBIN DIRECT:……………….

CHLORIDE:………… ALP:………………… PROTEIN TOTAL:……………………

UREA:………………. GGT:……………….. ALBUMIN:……………………………..

CREATININE:……………………………..

DATE OF CHEMOTHERAPY

1.

2.

3.

4.

5.