Management of Children With a Wilms Tumor in Malawi, Sub-Saharan Africa

Abstract

Wilms tumor has a survival rate of 85% to 90% in well-resourced countries. Malawi is a country in Sub-Saharan Africa with very limited resources. We evaluated the outcome of a treatment guideline including preoperative chemotherapy, supportive care, and strategies to enable parents to complete treatment. Between 2006 and 2011, 95 patients were initially diagnosed with a Wilms tumor; 11 were later excluded due to misdiagnosis. In 31% of patients, metastases were detected at presentation. Treatment outcomes in 8 patients with bilateral tumors and 3 patients who were referred after nephrectomy are analyzed separately. Treatment failed in 51% of 73 remaining patients. Reasons for failure were: 1) incomplete treatment (7%); 2) treatment-related deaths (15%); and 3) disease-related deaths (28%) with 11% unresectable tumors or metastases after preoperative chemotherapy and 17% relapse of disease. Projected survival is 46%. Challenges remain to improve survival for children with Wilms tumor in Malawi. Earlier diagnosis would reduce disease-related deaths as numbers of unresectable disease and relapse are high. Effective strategies, including social support, to enable parents to complete treatment need to be continued. Improved supportive care and nutritional support and possibly less intense preoperative chemotherapy are needed to reduce treatment-related deaths.

SIOP PODC: Clinical guidelines for the management of children with Wilms tumour in a low income setting

“…These are caused by surgical emergencies, lack of staff or theatre equipment. Still, delays in surgery are one of the known reasons of abandonment of treatment and are best avoided [3,5]. If a delay is unavoidable, we recommend continuing preoperative chemotherapy with vincristine only in an attempt to achieve some tumour control without risking neutropaenia at the time of surgery (EO).…”

“…Typical presentation of a child with Wilms tumour in a low income setting is a malnourished child of about 3 years with a large abdominal or flank mass, who is relatively well without acute pain or severe general malaise, but with haematuria and hypertension [3,4].…”

“…Are there abdominal or liver metastases? If possible estimate the size of the tumour by measuring the three dimensions (length  thickness  width  0.523 % volume (cm 3 ) to enable objective assessment of change in tumour size during treatment [15].…”

“…Survival in low income countries is much lower than in high income countries with reported survival in low income settings in sub-Saharan Africa ranging from 11% to 50% [3][4][5][6][7]. Known challenges are late presentation with advanced disease, malnutrition, failure to complete treatment and poorer facilities both for the specific cancer treatment and also for supportive care [4,5,8].…”

Treating Children With Cancer Worldwide—Challenges and Interventions

“…Reported survival rates of children treated for Wilms tumor in sub-Saharan Africa range from 11% in Sudan (where only 11% completed treatment), to 46% in Malawi. [8][9][10] Event-free survival was 61% for children treated for Burkitt lymphoma in Cameroon 11 and 56% for ALL in El Salvador. 12 Those who do access care often present with an advanced stage of disease and lower probability of cure.…”