INCTR Annual Report 2016

Branch: INCTR
President: Ian Magrath
Board Members: Louis Schoofs; Sultan Al-Sedairy, Nausherwan Burki, Max Parkin, Sidnei Epelman, Simon Sutcliffe, Martine Raphael, Robert Burton
Collaborators: St Mary's Hospital Lacor, Gulu, Uganda
Bugando Medical Centre, Mwanza, Tanzania
Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria
Partners: OFID
Global Health Dynamics
Challenge Fund
Global Giving
Address: INCTR
Rue Engeland 642
1180 Brussels
Country(s): Tanzania, Uganda, Nigeria,India
Year Established: 1998
Annual Report: Annual Report 2016
Future Plans: Expand educational and training activities in the principles of treatment and clinical care of Burkitt lymphoma, data management
Undertake site-visits in 2017 for purposes of training in the management of BL and also for review of pathology
Publications: Curing the Commonest Childhood Cancer in Equatorial Africa; Burkitt lymphoma: Explanatory information

Discovery of a Tumour

Burkitt lymphoma was recognised as a clinical syndrome by Denis Burkitt - an Irish surgeon who worked in British East Africa for the British Colonial Medical Service after the Second World War. Remarkably, it was not until 1957 - 10 years after his arrival in British East Africa (Uganda), that he saw a case. The hospital Pediatrician (Hugh Trowel) asked Burkitt to see a 5 year old boy with tumours that had developed in all 4 jaw quadrants. Burkitt could only confirm that the child had an inoperable cancer. Remarkably, just a week later, while visiting the District Hospital at Jinja (the location of the source of the Nile), he saw a second child with tumours present in all 4 jaw quadrants. This child also had palpable abdominal masses. Since Burkitt had never seen such a tumour, he studied pediatric case records to determine whether tumours of this type had been seen previously. As he soon discovered, a significant number of such cases has been seen. Fortunately, a cancer registry had been established some 7 years before, and after painstakingly examining the records Burkitt was able to identify a total of 37 children who had died with jaw tumours - often multiple and often associated with tumour at various other anatomical sites, particularly the abdomen. The tumour also quite frequently involved serous membranes, the orbits, endocrine glands, ovary, breasts and central nervous system. He also found a number of references to the tumour in the published literature. The professor of pathology, Jack Davies, could not make a diagnosis other than "small round cell sarcoma" and it was not until 1959 that Gregory O'Conor, a young pathologist recently arrived from the USA, reviewed, with Davies reviewed all the childhood cancers in the Kampala registry. O'Conor concluded that the tumour was a type of lymphoma. Remarkably, it accounted for 50% of all childhood cancers in the Kampala Cancer Registry.

Treatment of Burkitt Lymphoma

Determining optimal therapy for endemic Burkitt lymphoma is beset with problems, many arising from late referral and inadequate support. These differ little from those facing pioneer chemo therapists in the 1960's. Initially, the only feasible approach was trial and error, using drugs that had shown activity in other lymphoid diseases. Resection of jaw tumours was clearly not feasible, but the intensity of the response to intra-arterial infusions of methotrexate infused into the tumour showed excellent local responses, but patients died from tumour in the high concentration areas. This appproach showed dramatic results with methotrexate, demonstrating its effectiveness, but could not be used for patients with wide-spread tumour. Vincristine and cyclophosphamide appeared to be as active as methotrexate when given intravenously and the best route of administration of methotrexate was clearly intravenous. These encouraging results prompted the use of chemotherapy in many children as well as comparisons of the mode of administration although the studies were not nearly as rigorous in LMIC where even the validity of the diagnosis needs to be checked and all patients monitored carefullly - which is difficult to achieve in the lowest income countries- as they are today. For most drugs, the optimal dose and schedule has still not been determined, especially in the context of multiple drug regimens, but as experience of tolerance and effectiveness has increased, results have improved and in optimal circumstances in high income countries survival approaches 100%. In the early studies of methotrexate by Oettgen, Burkitt and Burchannal in 1963, for example, 2 of 31 had good responses but very few achieved long term survival and many were lost to follow up or had severe toxicity, making analysis impossible. Soon other drugs were studied, including mustine (which gave a poor result), cyclophosphamide and vincristine. Many patients achieved complete remission with these drugs used as single agents and and some long term results with one or two doses of these drugs were observed. Many other studies were using different drugs and doses have been performed since that time, but many factors impact upon the results, particularly late diagnosis, poor support and loss to follow up. In the INCTR study at Gulu, preliminary results of the first 118 patients suggested a long term survival rate of as much as 70%. This suggests that if these challenges could be overcome, it may be possible to cure as many as 75% of patients.

Throughout 2016, INCTR has provided guidance and consultation to INCTR India in its early stages of establishing itself within the state of Rajasthan. INCTR India has been able to develop a public private partnership with the state government of Rajasthan that supports its efforts. Presently, the branch has decided to begin its efforts by increasing public awareness about common cancers - cervical cancer, breast cancer and oral cancers. Using its advisors, they have trained senior nursing students about the early signs of these cancers and the students have been going to villages to raise public awareness by either making home visits or by marching through the streets. The students have been instrumental in collecting preliminary information about tobacco use and found that women are usually tobacco - usually in the form of tobacco-related products than was previously assumed. Nursing students who have been trained in early detection, of at least oral cancers, have been provided with referral guidelines to ensure that those individuals with suspected pre-cancerous or oral cancers are referred promptly for care. It is hoped that in 2017, it will expand these efforts and train state health workers - known as ASHAs to actually screen more for these common cancers and to expand efforts to be able to deliver palliative care to those living in the villages.
Month: 01
Year: 2016
Date of Last Report: 12/2015
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