|Year : 2016 | Volume
| Issue : 3 | Page : 127-131
Pattern and outcomes of childhood malignancies at Ahmadu bello university teaching hospital, Zaria
Hafsat Rufai Ahmad, Jamilu Abdullahi Faruk, Musa Abdullahi, Abiola Aira Olorunkooba, Hassan Ishaku, Fati Lami Abdullahi, Gboye Olufemi Ogunrinde
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Submission||07-Feb-2015|
|Date of Acceptance||29-Jun-2016|
|Date of Web Publication||19-Sep-2016|
Hafsat Rufai Ahmad
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Background: Childhood malignancies are associated with high mortality. Although prognosis and outcomes have improved significantly in developed countries, mortality is still very high in resource-poor settings. Objectives: This study aimed at determining the patterns and outcomes of childhood cancers over an 8-year period in a tertiary center of a developing country. Materials and Methods: A retrospective study of case notes of children admitted for cancer between January 2006 and December 2013. Results: Four hundred and twenty-six case notes of all children admitted with a diagnosis of cancer and also had a histological confirmation were analyzed. The cases accounted for 7.7% of the total admissions into the pediatric wards. More than half of the children 247 (57.9%) were under the age of 5 years, with a slight male:female preponderance of 1.4:1. Retinoblastoma had the highest frequency with 147 cases representing 34.5%, followed by Burkitt lymphoma with 67 cases (15.7%) and acute leukemia with 52 cases (12.2%). Surgery and chemotherapy were the most common modalities of treatment offered to about 80% of the cases. The mortality was high at 137 cases giving a mortality rate of 32.2% among the cancer cases and 2.5% overall from the pediatric wards. While 14 (5.8%) children were formally discharged, almost half of the total cases 224 (52.6%) abandoned treatment while 48 (11.4%) absconded or left against medical advice. Conclusion: The incidence of childhood malignancy was high with retinoblastoma being the most common malignancy encountered, and associated with high mortality and abandonment of treatment.
Keywords: Childhood, malignancy, outcomes, pattern
|How to cite this article:|
Ahmad HR, Faruk JA, Abdullahi M, Olorunkooba AA, Ishaku H, Abdullahi FL, Ogunrinde GO. Pattern and outcomes of childhood malignancies at Ahmadu bello university teaching hospital, Zaria. Sub-Saharan Afr J Med 2016;3:127-31
|How to cite this URL:|
Ahmad HR, Faruk JA, Abdullahi M, Olorunkooba AA, Ishaku H, Abdullahi FL, Ogunrinde GO. Pattern and outcomes of childhood malignancies at Ahmadu bello university teaching hospital, Zaria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2017 Dec 15];3:127-31. Available from: http://www.ssajm.org/text.asp?2016/3/3/127/190836
| Introduction|| |
Childhood cancers account for <10% of all human cancers, yet morbidity and mortality are very high.  In developed countries such as the USA,  the United Kingdom,  and the rest of Europe cancer incidence varies between 120 and 180 cases per million. 
Over the past 2-3 decades, there has been an increase in a number of childhood cancers worldwide presumably due to better diagnostic techniques and increasing exposure to environmental agents. ,,] Globally, about 200,000 children are diagnosed with cancer annually, and more than 80% are from developing countries.  While 7-8 out of every 10 children with cancer are cured in resource-rich settings, ,,, more than 70% of all cancer-related deaths occur in resource-poor settings.  More than 80% of children with cancer have little or no access to treatment even though childhood cancers are often amenable to cure even in resource-poor settings with simple and safe protocols. ,,
Given the huge burden of infections and malnutrition in Nigeria as in other low-income countries, , childhood cancer is not considered a priority, accounting for <1% morbidity and mortality in Nigerian children.  However, with success of vaccination strategies and some improvement of socioeconomic status, childhood malignancies, and other noncommunicable diseases are set to become increasingly important causes of morbidity and mortality in the near future.  Indeed, an increasing number of cases had been noted by casual observation and various researchers, associated with delayed presentation, advanced disease, and very poor outcome. ,, The mortality is remarkably high, in contrast with the developed countries where cure rates of up to 80% are achieved. ,, Apart from isolated hospital-based registries and reports of incidence and patterns of childhood cancers, there is paucity of studies or existence of a national cancer registry to document the burden and outcome of the disease in the various geographic locations in Nigeria. ,,,,, Late presentation has been found to be associated with increased of mortality. ,,
The aim of this study was to look at the patterns and outcomes of childhood cancers that were seen at the Department of Paediatrics, Ahmadu Bello University Teaching Hospital, (ABUTH), Zaria.
| Materials and methods|| |
The study was a retrospective review of case notes of all children aged 1-15 years admitted to the Paediatric wards of ABUTH, Zaria, over an 8-year period with a clinical diagnosis and histological confirmation of malignancy from January 2006 to December 2013. The hospital is a tertiary facility and a center for brachytherapy which receives referrals from all the 19 states of the Northern region. The pediatrics department manages children aged 1-16 years. All children over the age of 16 years were seen and managed in other clinical departments within the hospital. Children below the age of 16 years that were referred to and managed exclusively in other clinical departments such as pediatric surgical, radiotherapy and oncology, ophthalmology, and maxillofacial departments were not included in this study. Only cases with histological confirmation of cancer type were included; histology reports from referring physicians were included in the study. Results were analyzed using Microsoft Excel 2007 edition and presented in tables, figures, and percentages.
| Results|| |
A total of 467 children with clinical diagnosis of malignancy were identified, but 426 cases with histological confirmation of malignancy were analyzed. These cases represented 7.7% of the 5485 new admissions into the wards over the 8-year period. Two hundred and fifty subjects representing 58.7% of the children were males while 176 (41.3%) were females giving male:female ratio of 1.4:1. Two hundred and forty-seven children (57.9%) were under the age of 5 years [Table 1]. The age range was 11 months to 15 years, and the mean was 7.2 years ± 2.3. Retinoblastoma was the most common cancer seen in 147 cases accounting for 34.5% of the total as seen in [Table 2]. Of this number, 139, that is, 94.6% of the cases were post exenteration/enucleation and all presented with extraocular disease. The age range of presentation was 11 months to 6 years while the mean age was 2.3 ± 0.9. Of the 141 patients that received chemotherapy, 56 had completed the regime, but only 2 cases were formally discharged from follow-up. Five patients had radiation in addition to chemotherapy. Burkitt lymphoma was the next common cancer with 67 cases accounting for 15.7%. The mean age was 7.4 ± 1.9, and the age range was 1.5-9 years. Chemotherapy was the mainstay of treatment given to 49 (73.1%) of these children; the rest had supportive care only which consisted of antibiotics for infections, blood and blood products, nutritional support, and wound care. Acute leukemia was the most common hematological malignancy and the third common cancer seen accounting for 52 cases (12.2%). Acute lymphoblastic leukemia (ALL) accounted for 43 cases (82.7%) and acute myeloid leukemia accounted for nine cases (17.3%). The age range was 1-13 years and mean age at presentation was 6.7 ± 2.1. While 37 patients (71.2%) had started induction chemotherapy, the rest had only supportive care in form of transfusions, antibiotics, and analgesia and two cases were transferred to other centers. Nephroblastoma had 49 cases (11.5%), 30 (61.2%) of whom had both chemotherapy and nephrectomy, 11 (22.4%) had only pre-chemotherapy, and 8 (16.3%) had only surgery. Of the 11 cases documented to have completed chemotherapy, only 8 were formally discharged from clinic follow-up. Rhabdomyosarcoma had 30 cases representing 7.0%.
|Table 2: Types of malignancies seen at Ahmadu Bello University Teaching Hospital, Zaria|
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Surgery and chemotherapy were the most common treatment modalities as seen in [Figure 1]. Radiation was given to only five cases (1.2%) largely due to financial constraints and nonavailability of pediatric-focused radiation facilities. Two hundred and ninety-eight (~70%) children had chemotherapy including those that had neo and/or adjuvant treatment, 35 (8.2%) children had surgery and chemotherapy, while 8 (1.9%) had surgery only. The remaining 85 (~20%) children had only supportive care in form of blood transfusions, antibiotics, analgesics, nutritional rehabilitation, and wound care.
|Figure 1: The modalities of treatment of childhood malignancies at Ahmadu Bello University Teaching Hospital, Zaria|
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Among the 426 patients reviewed, 341 had one or more modalities of treatment and only 14 (5.8%) out of 23 cases documented to have completed treatment were formally discharged from clinic follow-up. These include 8 cases of nephroblastoma, 2 cases of retinoblastoma, 2 cases of Kaposi sarcoma, 1 Burkitt lymphoma, and 1 non-Hodgkin non-Burkitt lymphoma. About one-third of the cases, 137 died giving a hospital mortality of 32.2% among the 426 cancer cases and 2.5% of the overall mortality from pediatric wards (5485 new admissions during the period under review). Forty-eight children representing 11.4% absconded or left against medical advice, and 3 (0.7%) were transferred to other centers. Almost half of the total number of cases, 224 (52.6%), were lost to follow-up either during treatment or evaluation. Details of the outcomes for the five most common cancers are shown in [Table 3].
| Discussion|| |
Childhood cancers in ABUTH represented 7.7% of all new admissions in pediatrics wards between January 2006 and December 2013. Retinoblastoma was the most common cancer encountered followed by Burkitt lymphoma. The third most common malignancy which was also the most common seen hematological cancer was ALL. The mortality was high at 32.2% among the cancer cases and 2.5% overall from the pediatric wards. The incidence of childhood cancer in this review is higher than 0.9% that was obtained by Okocha et al. at Nnewi,  2.9% in Kano and 3.1% in Ife.  While this may be a true reflection of childhood cancer incidence in Zaria and its environs, it may also be due to the presence of Radiation and Oncology Department in our institution which is one of the main radiotherapy centers in the North West geopolitical zone. Indeed, Adewuyi et al.  had reported a high proportion relative to an overall number of cancers seen in the hospital (11.2%) of pediatric solid cancers seen between 2006 and 2010.  This may also be the reason for the yearly increase in a number of cases observed in this study [Figure 2], although increasing awareness about cancer, availability of health centers and higher index of suspicion as well as better diagnostic facilities may also have contributed. An increasing number of childhood cancers had been noted in other parts of the country such as Abakaliki.  The high frequency of embryonal tumors such as retinoblastoma and nephroblastoma could explain why children under 5 years of age are mostly affected. The male preponderance is in line with reports from other centers and regions within Nigeria ,,, and outside Nigeria such as Ghana  and Cote d' Ivoire.  In contrast to the previous studies from Zaria , and other parts of Nigeria such as Kano and Ife,  Enugu,  Nnewi,  Sokoto,  and Abakaliki,  which documented Burkitt lymphoma as the commonest childhood tumor, this study demonstrated retinoblastoma as the most common in Zaria. This finding, however, is not entirely surprising as Ojesina et al. in Ibadan in 2002, showed a decline in the frequency of Burkitt lymphoma over a 9-year period.  Tanko et al.  in Jos also observed that rhabdomyosarcoma was the most common solid childhood malignancy in a review that spanned over 5 years (January 2002-December 2006). A morphological study of childhood solid tumors seen between January 2000 and 2007 in Lagos University Teaching Hospital by Akinde et al.  documented retinoblastoma as the most common, while Adewuyi et al. from Radiotherapy and Oncology Department of ABUTH, Zaria demonstrated retinoblastoma as the most common childhood malignancy referred for radiation between 2005 and 2010.  On the other hand, the increasing number of pediatricians and federal medical centers in the Northern region that can easily administer chemotherapy for Burkitt lymphoma may explain the decline in referral of such cases to our institution. The presence of National Eye Center (a Tertiary Ophthalmology Institution) in Kaduna which is about 70 km away might have also contributed to the high referral of retinoblastoma cases for chemotherapy and/or radiation. Further study in the field is needed to fully understand and explain these changes.
|Figure 2: Yearly frequency of childhood malignancy cases over an 8-year period at Ahmadu Bello University Teaching Hospital, Zaria|
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Chemotherapy was the most common modality of treatment offered since the most common types of the malignancies respond well to chemotherapy and more than 95% of the retinoblastoma cases presented after exenteration or enucleation. Although the uptake of treatment was high at about 80%, the rate of abandonment of treatment, high mortality, and loss to follow-up are quite worrisome. These events could be explained by late presentation which could be gleaned at from the more than 95% of retinoblastoma that presented post enucleation/exenteration. In an analysis of cases of childhood mortality due to cancer in Ibadan by Brown et al., 71% of all the cases presented with a metastatic tumor.  Financial difficulties associated with poverty and nonavailability of health insurance, lack of awareness, belief for spiritual causes of illness by caregivers, lack of/difficulty in accessing appropriate treatment and supportive care services such as cytotoxic drugs, blood, and blood products as well as the absence of clinical trial protocols are some of the challenges that could explain the outcomes obtained in this review. However, a detailed analysis of these factors was not possible in this retrospective study due to lack of documentation.
Being a retrospective study, the determinants of delay in diagnosis and treatment could not be studied in this review; however, the unacceptably high mortality and abandonment of treatment make it necessary to define accurately the burden of cancer, determine where barriers exist, and intervention may be beneficial, and measure the outcome of interventions. The impact of delays on the outcome is also not studied, and this is important to determine the effects on caregiver and child well-being and confidence in the health care system as well as the cost which are likely to be enormous.
| Conclusion|| |
A high incidence of childhood malignancies associated with high a changing pattern of cancer types from previous documentation of Burkitt lymphoma is seen with retinoblastoma now being the most common childhood cancer encountered in Zaria. Although treatment uptake was high, the outcomes were poor with very high mortality and abandonment of treatment. Further studies are needed to ascertain and understand the underlying reasons for these observations and possible strategies to improve outcome.
I wish to acknowledge the contributions of all doctors, nurses, and social welfare workers who participated in the day-to-day care of these patients. The patients and their caregivers are also duly acknowledged.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]