“You might have a child with leukemia, and only three or four of the six or seven drugs that are needed to treat the leukemia optimally would be available,” said Dr. David Poplack, the director of Global HOPE, a Texas Children’s Hospital program working to improve pediatric cancer outcomes in Sub-Saharan Africa.

Supplies in many countries in the region are unreliable, and doctors frequently must rely on drugs of inferior quality. “One might treat a child with newly diagnosed leukemia, and notice that their hair doesn’t fall out,” usually a sign that the drugs are of suspect potency, Dr. Poplack said.

But the pandemic has made the process more difficult than ever. Uganda is on lockdown, which means all but essential businesses are closed, and most transportation – including passenger flights – are shut down. Fewer customs officials are working, and only a few hours a day when they are, according to Michelle Mugyenyi, a program manager for Global HOPE working on the ground in Uganda.

As a result, there is a shortage at Mulago National Referral Hospital, the largest pediatric oncology/hematology center in Uganda and one of the largest in Sub-Saharan Africa, Mugyenyi said.

The potential consequences of the delays and decreased capacity are grave, according to Joseph Lubega, a pediatric oncologist who is the associate director of the Global HOPE/Makerere University Pediatric Hematology/Oncology Fellowship training program and an assistant professor at Baylor College of Medicine.

“When you’re treating a child with cancer … [the supply] has to be reliable, because everything has to be administered according to a very stringent timeline,” he said. “If it shows up a week later, it may mean the difference between life and death for a child.”

But despite the difficulties, a shipment of cancer medicine and supplies from Direct Relief’s warehouse – a result of the partnership between the organization and Texas Children’s Global HOPE – cleared customs on April 17.

The shipment included the drug cyclophosphamide, donated by the global medical products company Baxter, used to treat lymphoma, leukemia and kidney cancer, among others.

“It’s a really critical drug in all the common childhood cancers,” Dr. Lubega said. When it comes to the importance of the shipment, “I can’t even describe it in words. It’s a godsend.”

That shipment will be the first of many. Through a partnership with Direct Relief, the pharmaceutical company Teva will provide oncology drugs to Global HOPE’s program in Malawi beginning in 2020. Teva’s support will extend to Botswana and Uganda in early 2021.

Ambition and Aspiration

Dr. Lubega remembers a time – before Global HOPE began its work in 2016 – when there were no pediatric oncologists in Uganda.

When he was in medical school, “cancer wards were really death traps,” he recalled. “The expectation was that the child is diagnosed with cancer … we go through the motions, and soon they’re going to die.”

Dr. Lubega decided he was going to become a pediatric oncologist – but at the time, there were no training centers in Sub-Saharan Africa. So he went first to England for training, and then to the United States, where he received a fellowship from Texas Children’s Hospital.

Texas Children’s Hospital, under the umbrella of the Baylor International Pediatric AIDS Initiative, was already working with children with HIV/AIDS in Sub-Saharan Africa. In 2016, they sent Dr. Lubega to Uganda to establish a training program for pediatric cancer and blood specialists.

Texas Children’s Global HOPE program, which works to improve outcomes for children with cancer in Sub-Saharan Africa, works by establishing and developing training programs for hematologist-oncologists, and other specialists whose work is essential to successful cancer treatment; increasing the capacity and success of treatment programs; and improving access to life-saving cancer drugs.

“The stimulus behind our developing Global HOPE was the realization of the underlying, horrendous inequity between the outcome of children in Sub-Saharan Africa and children in the United States and Europe,” Poplack explained.

Establishing a training program was an ideal fit for the organization’s work. However, Dr. Lubega admitted, at the time he was more driven by “ambition and aspiration than having a concrete understanding of how this was going to go.”

At the time, there were no fully trained pediatric hematologist-oncologists and only a handful of nurses supporting children with cancer.

Drug supplies were unreliable and as a result, treatment protocols were haphazard at best.

Only 30% of children survived a month after beginning treatment.

The problem wasn’t a lack of health care providers, Dr. Poplack explained. “The pediatricians we work with are extremely well-trained, extremely capable,” he said. “What they lacked was specific subspecialty training in pediatric hematology-oncology, the modern clinical equipment and approaches to make an accurate diagnosis and then, the drugs and therapies that are needed once the diagnosis is made.”

Dr. Lubega set about training nursing staff, pharmacists, and the necessary specialists. He introduced evidence-based protocols.

But, “most important was really a culture change, that…these children can really be cured, they can be saved.”

Things changed quickly. “By the end of the first year, the [one-month] survival rate of kids we treated was up to 85%,” Dr. Lubega said. Over half survived for 18 months or longer.

Changing a Culture

There’s still a long way to go, according to  Dr. Lubega. “The reality is we are still just scratching the surface. Only 10 to 15% of kids in Africa with cancer ever see a cancer doctor, ever realize they have cancer.”

Cancer care is a multidisciplinary process, and some resources – pediatric surgeons, ICU units, pharmacists – are still extremely hard to come by.

Complicating matters is the fact that there seem to be some slight differences – possibly genetic, possibly environmental – between pediatric cancers in Africa and in the United States, but it’s impossible to study further until basic, reliable treatment protocols are established.

And then there’s the issue of oncology drugs, which are difficult for most families – or even governments – to afford.

Improved access to drugs won’t just improve outcomes for individual patients, Dr. Lubega said. It has the potential to change the culture around cancer care in Sub-Saharan Africa.

As the latest drugs become available, survival of children is improving, and a cure is becoming a reality for an increasing number of children, both Dr. Poplack and Dr. Lubega said.

Historically, the public understanding of childhood cancer has been limited. “In many of the villages and towns, there’s little awareness of what cancer is and that children do suffer from cancer,” Dr. Lubega explained. “People who have cancer are sometimes shunned, and there’s a significant stigma. It’s oftentimes considered infectious.”

Global HOPE also conducts community awareness and patient outreach programs designed to increase awareness of childhood cancers – and encourage people to take advantage of treatment.

The organization wants to change the culture around childhood cancer in Sub-Saharan Africa. “This is our number one priority if we as Global HOPE can show we can cure kids with cancer in the African setting,” Dr. Lubega said.

And drugs are an essential part of that, he explained: “If we have a stable supply of the chemotherapy agents, we can radically improve the survival statistics for tens of thousands of children.”

What’s Possible

COVID-19 has introduced some temporary challenges. Drugs are harder to come by. Because public transportation has shut down, it’s harder for patients to receive treatment.

“Our team is having to drive to the patients’ homes and administer chemotherapy there if it’s possible,” Dr. Lubega said.

And Dr. Lubega himself, for the time being, can’t return home. “I miss being part of it, because the difference between there and my work in the U.S. is the impact you make,” he said, speaking from Texas.

“I’m one of many, many pediatric oncologists here. There, you are making a real, paradigm-shifting impact in terms of what’s possible for those children.”

Working with Direct Relief and Teva will mean a long-term supply of precisely the drugs that will improve outcomes for children – and, with luck, encourage families to seek care and health officials to treat pediatric cancer as more of a priority.

Dr. Poplack is optimistic. “If we can improve the survival rate by 40% – and we’ll ultimately go far beyond that – 40,000 children can be saved each year,” he said. “I know of no other medical activity where one can have that kind of impact.”

The post Children’s Cancer Drugs Are Scarce in Uganda. A New Partnership Is Changing That. appeared first on Direct Relief.

But a small number of doctors spread throughout Africa, some of whom are backed by a $50 million grant, have seen outcomes begin to approach Western numbers. This has led to hope that widespread improvements — for cancer treatment and beyond — could be attainable within years.

“We realized that some of these cancers are highly, highly curable, and the kids bounce back fast,” said Dr. Fredrick Chite Asirwa, who established a program in Kenya with Takeda Pharmaceuticals, Indiana University, and Moi University that brought survival rates above 80% and has overseen the oncology training of about 700 doctors, nurses, and physicians assistants, in addition to “spotters” who are taught how to identify tumors in residents of remote villages.

“In Kenya, everyone thought cancer was a death sentence. There were not many survivors,” Asirwa said. His work in western Kenya has led to vastly improved access to pediatric cancer care. The number of patients his programs treat has grown from 400 people in 2011 to 10,000 people in 2017.

Though differing challenges face health care providers, as well as patients and their families throughout Africa, some commonalities include a lack of oncology-trained doctors and nurses, misdiagnoses, financial impediments, and a lack of access to authentic, high-quality medicines. This latter issue is due, in part, to logistical challenges related to safely delivering and storing those medicines.

While they can’t remedy all those ills, some enterprising doctors have been able to implement new protocols and training forums, which have enabled more children to be accurately diagnosed and treated.

Notably, only 50 years ago, the United States had a 90% pediatric cancer fatality rate, according to a 2008 Seminars in Oncology report, giving hope that immense improvements can be had in Africa as well.

In Tanzania, Dr. Trish Scanlan, in partnership with the local government, has overseen the treatment of thousands of cases, and all at no charge to the families involved. About half of children diagnosed with cancer survive at Muhimbili National Hospital, one of the facilities she works with. They have accomplished this without even having a cold storage room, which is needed for certain medicines, and which Direct Relief is helping them build.

“There are so many problems that already have solutions. We’re not inventing something… This is imminently solvable in a very, very short period of time,” she said, referring to pediatric cancer cure rates.

And in Malawi, one of the poorest countries in the world, Nigerian-born Dr. Nmazuo “Maz” Ozuah is leading the way for Global HOPE, a Texas Children’s Hospital program that is using a $50 million grant from the Bristol-Myers Squibb Foundation to build capacity throughout Africa. His program hopes to treat 4,000 new pediatric cancer patients in Malawi during the next five years.

Despite only being in-country for a few months full-time, Ozuah has already seen positive changes, both in pediatric cancer care and in other types of medical treatment.

“I see that our presence here has strengthened the whole system. In order to treat children with cancer, you need a strong health care system,” he said at the AORTIC Conference in Nov. 2019, noting that solid laboratory work, training, and public advocacy, as well as awareness, are all critical.

Ozuah, who completed his residency and fellowship in the United States, said he was acutely aware of the deep systemic problems facing pediatric cancer care during his internship in Nigeria.

“As an intern, once you said a patient had cancer, you were left off the hook. No one expected you to explain why that child died,” he said.

Aiding Global HOPE’s potential ability to bring massive improvements in this area, Teva last week became the first pharmaceutical company to donate medicines to the program. Starting with a limited pilot program this year, their products will be delivered by Direct Relief to Global HOPE programs in Malawi and then Botswana and Uganda in 2021.

“Somebody (Direct Relief) cracked how to do safe deliveries of these medicines. So our sense was that it would be interesting to partner with Global HOPE,” said Amalia Adler-Waxman, Teva’s Vice President of Social Impact and Responsibility, on why the company decided to engage.

While there are bright spots, creating a sea change will require addressing problems that have been present for decades or longer, in some cases.

Asirwa said that one of the most damaging issues is the pervasive ignorance facing fundamental elements in treating pediatric cancer. One example, he shared, was a belief that survival rates are low in Africa because patients only come after they are in the later stages of the disease.

“Most patients see 8-10 health care professionals before the correct diagnosis is made,” he said, adding that one of the reasons behind this is that African doctors often have to go abroad to receive training in oncology — and once in those countries, they tend to stay.

Even when a correct diagnosis is made, high costs also delay treatment. Asirwa said that, even though Kenya has national health care, it doesn’t cover all aspects of cancer treatment. An accurate diagnosis can cost $250, and so many patients have to delay the process until they can raise the cash.

Drug shortages and costs also play a role, and Asirwa said he saw a child recently who was only taking three out of the five required medicines for his condition.

While HIV/AIDS treatment is often seen as a template for how to treat cancer in Africa, Asirwa urged caution, noting that HIV is one disease, whereas cancer consists of many diseases. Still, there is some value to the general idea of creating effective protocols and then exporting them, he said.

“If you use that model and take it to cancer, it will be much easier to improve the system.”

Dr. Asirwa, along with Scanlan and Ozuah, referenced the multidisciplinary approach needed to improve outcomes for pediatric cancer care. Asirwa said in an American Society of Clinical Oncology-published essay that this also extends to the janitors, in his experience.

Patients in Kenya often wait for hours to be seen by a doctor, he wrote, and in that time they can become emotional and nervous. Such a patient could turn to the only clinic staff who is constantly around — the janitor — and ask, “Have you seen any patients like me here at this clinic being treated?”

“Yes,” the janitor answers.

The next and most important question is asked: “How did they do? Did they get cured?” Asirwa wrote, and included that he thinks janitors should be educated on the different kinds of cancers, that some can be cured, the importance of getting a biopsy, and, “that they are IMPORTANT to the team!”

The underlying issue gets at one of the most difficult problems to solve, namely, public perception. But Asirwa has a plan for that, too.

“There is nothing more powerful than actually seeing a survivor,” Asirwa said. “You can actually start making people believe that cancer can cured.”

Direct Relief, Global HOPE and Teva Pharmaceuticals are partnering to expand access to cancer treatment in sub-Saharan Africa. Under this partnership, Global HOPE determines the specific medications needed at its clinical sites for treating cancer and blood disorders in children. Those medications, in turn, are provided by Teva to Direct Relief for delivery. The collaboration is the latest in a series of Direct Relief efforts to connect cancer treatments to patients around the world, including support for pediatric cancer patients in Mexico, and the Philippines, as well as cancer initiatives in Haiti, Nepal and Peru. Direct Relief is also a member of the Union for International Cancer Control (UICC), as well as an implementing partner in the City Cancer Challenge Foundation (C/Can).

The post In Sub-Saharan Africa, Childhood Cancer Is Often Deadly. A New Initiative Is Working to Change That. appeared first on Direct Relief.

Under this partnership, Global HOPE will determine the specific volumes and quantities of medications identified for current patient needs at its clinical sites. Teva will provide essential medications for treating cancer and blood disorders in children to Direct Relief, who will, in turn, ensure the efficient shipping and delivery of the donated medicines in coordination with Global HOPE facilities.

“The success we’ve had in radically changing the course of pediatric cancer and hematology in sub-Saharan Africa is due in large part to our partners and donors who have made our work possible,” said Dr. David Poplack, Director of Global HOPE. “By partnering with a global leader in generic and specialty medicines like Teva along with Direct Relief’s experience in cold chain logistics, we can have an immediate and sustained impact in low- and middle-income countries where increased access to pediatric oncology treatments is desperately needed.”

Teva will initially support the Global HOPE program in Malawi, with the potential to extend access of donated medicines to other Global HOPE sites across sub-Saharan Africa. Teva’s donation of medicines through this partnership will support the treatment plans for almost 95% of all chemotherapy patients. Over the next five years, Global HOPE anticipates diagnosing and treating close to 4,000 new pediatric cancer patients in Malawi.

“This initiative with Global HOPE and Direct Relief can bring medicines to thousands of children with cancer and blood disorders in African countries,” said Amalia Adler-Waxman, VP Social Impact and Responsibility at Teva. “Supporting this critical supply chain along with our partners allows us to facilitate access to pediatric oncology treatments while laying the groundwork for Global HOPE and others to also potentially treat pediatric illnesses beyond cancer and hematologic disorders.”

As an organization with decades of global supply chain and logistics expertise, Direct Relief will play a leading role in the distribution of donated prescriptions product from Teva. Direct Relief’s shipments of donated medicines from Teva will be shipped to one of the designated local Global HOPE-affiliated NGOs in Malawi, Botswana and Uganda.

“Direct Relief is deeply appreciative to Teva and Global HOPE for their leadership and initiative in providing critical treatments to children in Africa and globally,” said Thomas Tighe, President and CEO of Direct Relief. “Thanks to this collaboration, children who would otherwise be unable to access cancer therapies will be able to receive the treatments they need.”

The partnership was announced for International Childhood Cancer Day. International Childhood Cancer Day is a global collaborative campaign to raise awareness and promote an increased appreciation and deeper understanding of the challenges faced by children and adolescents with cancer, the survivors and their families.

The post Global HOPE, Teva and Direct Relief Partner for Increased Access to Pediatric Cancer Therapies in Africa appeared first on Direct Relief.