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Examining care pathways and their effect on the survival outcome of children with acute lymphoblastic leukaemia in sub-Saharan Africa - NU/LSHTM project

Supervisory team

LSHTM


Nagasaki University


Advisory Committee 

Project

Background 

Acute lymphoblastic leukaemia (ALL) is a treatable and often curable disease in children, with significantly improved survival rates in high income countries (HICs). However, the situation remains alarming in low- and middle-income countries (LMICs) including Sub-Saharan Africa (SSA). Challenges persist across the care pathway in LMICs, including limited access to early diagnosis, delayed presentation, co-existing health conditions, and malnutrition hindering treatment effectiveness. 

In LMICs, patients may succumb to leukaemia due to missed early diagnoses or misdiagnoses. Some deteriorate during the diagnostic process because leukaemia diagnosis often requires morphological evaluation and immunophenotyping through pathology and flow cytometry, which are not always available in LMICs. Access to treatment is hindered by financial constraints, long distances to paediatric oncology centres, and treatment availability. The actual number of patients in specialised hospitals is likely underestimated. 

A current study in Tanzania found that a 2-year event-free survival for children with ALL is 38%, in contrast to the often above 90% in HICs. The study revealed various issues such as early deaths due to infection and bleeding complications, high relapse rates, and treatment abandonment in both initial and late phases of treatment. Due to the retrospective design of the study, the study was not able to collect all relevant information and to evaluate the underlying causes of such issues.  

Understanding the challenges in childhood leukaemia is essential, considering factors like limited public awareness, diagnostic and treatment difficulties, and infectious disease management complexities such as co-infections and comorbidities. 

Aim

To understand the overall management of childhood leukaemia in SSA. This research aims to develop a comprehensive understanding of the challenges associated with children with ALL, improve data accessibility and management, and identify policy recommendations to enhance care for children with leukaemia in resource-constrained settings. 

Objectives 

  1. To assess public awareness of leukaemia using a questionnaire survey. Leukaemia shares symptoms with common childhood illnesses, potentially causing delays in leukaemia diagnosis as children are initially treated for other infectious diseases. 
     
  2. Perform situation assessment of existing data sources for childhood cancer in SSA.  
     
  3. To facilitate the transition from paper-based data systems to electronic databases. This effort is intended to address the challenges associated with the limited availability of electronic data in SSA. The approach involves partnering with governments, policymakers and health professionals to establish a sustainable strategy for implementing cancer registries. 
     
  4. To investigate complex care pathways for children with leukaemia who are presented in hospitals. This involves studying diagnostic pathways, referrals, late disease presentation, and treatment delays in SSA. Sample indicators may include the number of primary care visits before referral to tertiary care providers, number of health care providers consulted before appropriate referral, training, having an insurance, and resources offered to patients, among others.  
     
  5. To use causal analysis methods to examine survival outcomes. This analysis will explore the impact of patient characteristics, clinical factors, disease factors (such as co-infections), and geographical variations on leukaemia survival rates. 
     
  6. To identify policy implications for improving care in SSA: This objective involves assessing organisational improvements by growing networking between paediatric units in SSA.  
     

Data sources  

The potential data sources include but are not limited to (see more details in further box); hospital-based cancer registries from Muhimbili Hospital (Dar es Salaam), Ocean Road Cancer Institute (Dar es Salaam), Kilimanjaro Christian Medical Centre (Kilimanjaro), Bugando Medical Centre (Mwanza), Sengerema District Hospital (Mwanza), Benjamin Mkapa Hospital (Dodoma), Lindi Regional Referral Hospital (Lindi), Mbeya Zonal Referral Hospital (Mbeya), St. Francis Referral Hospital (Morogoro),  Mnazi Mmoja Referral Hospital (Zanzibar) and a cross-sectional questionnaire survey. 

References

Moleyneux E, Scanlan T, Chagaluka G, et al. Haematological cancers in African children: progress and challenges. Br J Haematol. 2017 Jun;177(6):971-978. 

Kersten E, Scanlan P, Dubois SG, et al. Current treatment and outcome for childhood acute leukemia in Tanzania. Paediatric Blood Cancer. 2013 Dec;60(12):2047-53. 

Cohler C, Jumanne S, Kaijage J, et al. Evaluation and outcome of central nervous system involvement in pediatric acute lymphoblastic leukemia in Dar es Salaam, Tanzania. Pediatric Blood Cancer. 2016 Mar;63(3):458-64.  

Schroeder K, Saxton A, McDade J, et al. Pediatric cancer in northern Tanzania: evaluation of diagnosis, treatment, and outcomes. J Glob Oncol. 2018;4: JGO.2016.009027.
 

The role of LSHTM and NU in this collaborative project

The Inequalities in Cancer Outcomes Network (ICON) group at LSHTM offers academic training in quantitative analytic methods, supports co-supervision. NU participate in co-supervising the research project with a clinical expertise. This project will build upon the recent collaborations between LSHTM, NU, research institutions and hospitals in SSA. 

Other Collaborations

While our current focus and collaborations are primarily in Tanzania, we have also established connections with researchers from the African Center for Research on End of Life Care (ACREOL). We are looking forward to expanding our partnerships to include the MRC Gambia, Uganda, and Kenya, thereby broadening our reach to multiple centres across countries in SSA. 

Particular prior educational requirements for a student undertaking this project

  • A master's degree in epidemiology, public health, applied biostatistics or a related field relevant to the project.
  • An upper second-class degree from a UK university or an equivalent qualification from an overseas institution in a subject related to the project. 

Skills we expect a student to develop/acquire whilst pursuing this project

The student will:

  • Develop expertise in childhood cancer epidemiology.
  • Gain experience in modelling observational data.
  • Work with diverse data sources, including hospital-based cancer registries.
  • Formulate and conduct surveys.
  • Producing policy-relevant research.
  • Work at the intersection between academia and practice.