Towards zero percent treatment abandonment of patients with common and curable childhood cancer types in Blantyre, Malawi

Abstract

Background: Treatment abandonment is a common cause of treatment failure in lowincome countries (LIC). We implemented a comprehensive package of interventions aiming to enable all families to complete the treatment of their child. The objective of this study was to evaluate the impact of those interventions. Procedure:In this prospective and historically controlled study, we included all children younger than 16 years with a newly diagnosed common and curable cancer type (acute lymphoblastic leukaemia [ALL], Hodgkin disease, Wilms tumour, retinoblastoma and Burkitt lymphoma) admitted to the Queen Elizabeth Central Hospital in Blantyre, Malawi, between 1 June 1 2019 and 1 June 1 2020. Interventions to enable treatment completion included full funding of costs to the family (treatment, transport, accommodation and food in the hospital) and tracking of patients if they did not attend treatment appointments. The outcomes of patients were compared with those of a similar historical cohort. Results:The intervention cohort of 150 patients were compared to 264 historical control patients. Treatment abandonment decreased significantly from 19% (49/264) to 7% (10/150) (p < .001). The proportion of patients with Wilms tumour, retinoblastoma or ALL alive without evidence of disease at the end of treatment increased from 38% (57/149) to 53% (44/83) (p = .03). Conclusion:A simple and relatively low-cost comprehensive intervention package with no costs for families, significantly decreased treatment abandonment. This strategy may increase survival of children with common and curable cancers in LIC, especially when coupled with improvements in access to treatment and quality of treatment, including supportive care.

Prevention of treatment abandonment in sub‐Saharan Africa; Lessons learned in Malawi that guide the way forward to cost‐effective interventions: A report from CANCaRe Africa

“…Transport costs are the most important component of out‐of‐pocket costs. With cover of all transport costs, treatment abandonment decreased significantly from 19% (49 of 264) to 7% (10 of 150); p < .001 14,15 . The proportion of patients alive and without evidence of disease at the end of treatment increased from 53% (139 of 264) to 61% (91 of 150), but was not statistically significant ( p = .1).…”

“…The intervention consisted of financial cover of all transport costs during the whole treatment, on average 200 Euro per patient. 14 Families in Malawi do not have to pay for diagnosis, treatment, or accommodation while staying at the hospital and receive two free meals per day. Transport costs are the most important component of out-of-pocket costs.…”

“…However, a significant increase in the proportion of patients alive without evidence of disease at the end of treatment was demonstrated from 38% (57/149) to 53% (44/83) (p = .03) in patients with the most significant decrease in abandonment (Wilms tumor, retinoblastoma, and acute lymphoblastic leukemia [ALL]). 14 Analysis of cost-effectiveness of interventions is crucial to assess affordability and sustainability, especially in countries with limited and strained health budgets such as in sub-Saharan Africa. Childhood cancer treatment itself was found to be very cost-effective in two and cost-effective in one out of four centers across sub-Saharan Africa, and evidence from simulations suggests that interventions to prevent treatment abandonment in sub-Saharan Africa are likely to be costeffective.…”

“…We piloted the implementation of such an incentive to primary caregivers of children with newly diagnosed common and curable cancers in Malawi. The intervention consisted of financial cover of all transport costs during the whole treatment, on average 200 Euro per patient 14 . Families in Malawi do not have to pay for diagnosis, treatment, or accommodation while staying at the hospital and receive two free meals per day.…”

“…The proportion of patients alive and without evidence of disease at the end of treatment increased from 53% (139 of 264) to 61% (91 of 150), but was not statistically significant ( p = .1). However, a significant increase in the proportion of patients alive without evidence of disease at the end of treatment was demonstrated from 38% (57/149) to 53% (44/83) ( p = .03) in patients with the most significant decrease in abandonment (Wilms tumor, retinoblastoma, and acute lymphoblastic leukemia [ALL]) 14 …”