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\begin{document}

\title{Childhood cancer care in Cameroon: Bottlenecks and Opportunities}



\author[1]{Andreas Frambo}%
\author[2]{Berthe Sabine Esson Mapoko}%
\author[3]{Valirie Ndip Agbor}%
\author[4]{Joseph Nkfusai}%
\author[1]{Sophie De Chazal}%
\author[5]{Nyemb Mbog Grace}%
\author[5]{Armelle Kamdem}%
\author[6]{Glenn Mbah}%
\author[7]{Francine Kouya}%
\author[1]{Emily Kobayashi}%
\author[8]{Ousmane Diaby}%
\author[2]{ANGELE PONDY}%
\author[2]{Paul Ndom}%
\author[1]{Yauba Saidu}%
\affil[1]{Clinton Health Access Initiative}%
\affil[2]{Universite de Yaounde I Faculte de Medecine et des Sciences Biomedicales}%
\affil[3]{University of Oxford Nuffield Department of Population Health}%
\affil[4]{University of Buea Faculty of Health Sciences}%
\affil[5]{Chantal Biya Foundation}%
\affil[6]{University of Bamenda}%
\affil[7]{Mbingo Baptist Hospital}%
\affil[8]{Universite de Ngaoundere Faculte des Sciences}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
\textbf{Background} Childhood cancer is the sixth leading cause of
global cancer burden. Indeed, 90\% of childhood cancer cases occur in
low-middle-income countries (LMICs), where mortality can be 4-5 times
higher than in high income settings. In addition, many LMICs lack data
on pediatric oncology for policy development and resource
prioritization. In this paper, we describe the state of pediatric cancer
care and treatment in Cameroon. \textbf{Procedure} We conducted
cross-sectional survey in July 2020, which enabled us to collect data
from two hospitals providing pediatric oncology services in Cameroon. We
collected data on service availability, human resource capacity,
frequent cancer types, treatment dropout, primary reasons for drop out,
disclosure of status, and management of oncology data. \textbf{Result}
The surveyed hospitals offered both pediatric chemotherapy and
palliative care services; however, none offered nuclear medicine or
radiotherapy services. In terms of workforce, human resources were
grossly lacking in both hospitals. The available ones include one
pediatric hemato-oncologist, one medical oncologist, one resident
pediatric oncologist, one pediatric surgeon, and 14 oncology nurses and
about 40\% (18/45) of have received specialty training in oncology. The
commonest childhood cancer managed in these facilities, was Burkitt
lymphoma, (39, 23\%). About 30\% of children on chemotherapy abandoned
their treatment, primarily due to lack of funds to continue with
treatment sessions. In both settings, the capacity to diagnose cancer
and provide counselling was limited. In addition, the tools to capture
and transmit data varied by facility, resulting to different data set
being generated. Furthermore, both facilities, had no schedule and
timelines for data reporting. \textbf{Conclusions} Our results suggest
that several factors negatively impact proper cancer care and treatment
of pediatric Cancers in Cameroon. These include, inadequate human
resource capacity, a high proportion of dropouts from chemotherapy due
to high cost, and lack of harmonized data collection and reporting tools
and systems. Systematically addressing these factors could contribute to
improving treatment outcomes for pediatric cancer patients in Cameroon.%
\end{abstract}%



\sloppy


\textbf{Childhood cancer care in Cameroon: Bottlenecks and
Opportunities}

Andreas Frambo*\textsuperscript{1}, Berthe Sabine Esson
Mapoko\textsuperscript{2,9}, Valirie Ndip Agbor\textsuperscript{3},
Joseph Nkfusai\textsuperscript{4}, Sophie De Chazal\textsuperscript{5},
Nyemb Mbog Grace\textsuperscript{10}, Armelle
Kamdem\textsuperscript{10}, Glenn M. Afungchwi\textsuperscript{6,7},
Francine Tchintseme\textsuperscript{7}, Emily
Kobayashi\textsuperscript{5}, Ousmane Diaby\textsuperscript{11}, Angelle
Hermine Pondy\textsuperscript{2,10}, Paul Ndom\textsuperscript{2,9},
Yauba Saidu\textsuperscript{1,8}

\begin{enumerate}
\tightlist
\item
  Clinton Health Access Initiative, Yaound\selectlanguage{ngerman}é, Cameroon
\item
  Faculty of Medicine and Biomedical Sciences, University of Yaoundé I,
  Cameroon
\item
  Nuffield Department of Population Health, University of Oxford,
  Oxford, UK
\item
  Faculty of Health Sciences, University of Buea, Cameroon
\item
  Clinton Health Access Initiative, Boston, USA.
\item
  Faculty of Health Sciences, The University of Bamenda, Cameroon
\item
  Mbingo Baptist Hospital, Bamenda Cameroon
\item
  Institute for Global Health, University of Siena, Siena, Italy
\item
  National Committee for the Fight Against Cancer, Yaoundé Cameroon
\item
  Mother and Child Center, Chantal Biya Foundation, Yaoundé Cameroon.
\item
  Faculty of Economics and Management Sciences, University of
  Ngaoundere, Cameroon.
\end{enumerate}

\textsuperscript{*} Correspondence to:

Andreas Frambo MD, MPH, MBAc, Program Manager, Non-Communicable Diseases

Clinton Health Access Initiative Yaoundé, HS Jean Paul II Boulevard,
Tsinga Sous-Préfecture Yaoundé, P.O Box 5241. Tel +237-694-743-523, or
+237-677-029-572, Email:aframbo@clintonhealthaccess.org

Text word count 3252;

Abstract word count: 253;

Brief running title: Childhood cancer care in Cameroon: Bottlenecks and
Opportunities

Key words: pediatric cancer, treatment access, data management,
Cameroon.

Tables: 5

Figures: 2

\textbf{Abbreviations}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{CNS} & Central Nervous System\tabularnewline
\textbf{CFA} & Central African Franc\tabularnewline
\textbf{CPS} & Cancer Prevention Studies\tabularnewline
\textbf{DALY} & Disability Adjusted Life Years\tabularnewline
\textbf{DHIS} & District Health Information System\tabularnewline
\textbf{GFAOP} & Group Franco-Africain d'Oncologie
P\selectlanguage{ngerman}édiatrique\tabularnewline
\textbf{HCW} & Health Care Worker\tabularnewline
\textbf{LMIC} & Low- and Middle-Income Country\tabularnewline
\textbf{MBH} & Mbingo Baptist Hospital\tabularnewline
\textbf{MCC/CBF} & Mother and Child Centre of the Chantal Biya
Foundation\tabularnewline
\textbf{MOH} & Ministry of Public Health\tabularnewline
\textbf{SGOT} & Serum glutamic oxaloacetic transaminase\tabularnewline
\textbf{SGPT} & Serum glutamic pyruvic transaminase\tabularnewline
\textbf{USD} & United States Dollars\tabularnewline
\bottomrule
\end{longtable}

\section*{Abstract}

{\label{abstract}}

\textbf{Background}

Childhood cancer is the sixth leading cause of global cancer burden.
Indeed, 90\% of childhood cancer cases occur in low-middle-income
countries (LMICs), where mortality can be 4-5 times higher than in high
income settings. In addition, many LMICs lack data on pediatric oncology
for policy development and resource prioritization. In this paper, we
describe the state of pediatric cancer care and treatment in Cameroon.

\textbf{Procedure}

We conducted cross-sectional survey in July 2020, which enabled us to
collect data from two hospitals providing pediatric oncology services in
Cameroon. We collected data on service availability, human resource
capacity, frequent cancer types, treatment dropout, primary reasons for
drop out, disclosure of status, and management of oncology data.

\textbf{Result}

The surveyed hospitals offered both pediatric chemotherapy and
palliative care services; however, none offered nuclear medicine or
radiotherapy services. In terms of workforce, human resources were
grossly lacking in both hospitals. The available ones include one
pediatric hemato-oncologist, one medical oncologist, one resident
pediatric oncologist, one pediatric surgeon, and 14 oncology nurses and
about 40\% (18/45) of have received specialty training in oncology. The
commonest childhood cancer managed in these facilities, was Burkitt
lymphoma, (39, 23\%). About 30\% of children on chemotherapy abandoned
their treatment, primarily due to lack of funds to continue with
treatment sessions. In both settings, the capacity to diagnose cancer
and provide counselling was limited. In addition, the tools to capture
and transmit data varied by facility, resulting to different data set
being generated. Furthermore, both facilities, had no schedule and
timelines for data reporting.

\textbf{Conclusions}

Our results suggest that several factors negatively impact proper cancer
care and treatment of pediatric Cancers in Cameroon. These include,
inadequate human resource capacity, a high proportion of dropouts from
chemotherapy due to high cost, and lack of harmonized data collection
and reporting tools and systems. Systematically addressing these factors
could contribute to improving treatment outcomes for pediatric cancer
patients in Cameroon.

\textbf{Keywords:} pediatric cancer, treatment access, data management,
Cameroon.

\section*{Introduction}

{\label{introduction}}

Survival from childhood cancers has improved tremendously over the last
five decades {[}1{]}. Indeed, about 80\% of childhood cancers can be
successfully treated in high-income settings with good access to modern
treatments and supportive care. Unfortunately, about 90\% of children at
risk of childhood cancer each year reside in developing countries, with
limited availability and accessibility to technical platforms for early
diagnosis and management of childhood cancers {[}2--5{]}. Since children
depend on their parents or carers, their symptoms might be overlooked,
leading to delayed diagnosis, misdiagnosis and late treatment
initiation, eventually leading to poor patient outcomes {[}6{]}. In
addition, children are often neglected in cancer control programs,
partly because of a paucity of data on childhood cancer risk and
survival {[}7{]}.

In 2019, pediatric cancers represented the sixth leading cause of the
global burden of cancers and the ninth leading cause of global childhood
disease burden {[}1{]}. Despite representing only 1\% of global cancer
cases diagnosed yearly, childhood cancers are associated with
disproportionately high disability-adjusted life-years (DALYs) because
children have a longer life expectancy. For instance, over 80\% of the
11.5 million DALYs attributed to childhood cancers in 2019 occurred in
LMICs {[}1{]}.

In Cameroon, childhood cancers account for 1 to 2\% of all cancers, and
malignant hemopathies like acute lymphoid leukemia (ALL) and acute
myeloid leukemia (AML) represent about 50\% of childhood cancer cases.
Although 90\% of these cancers are curable, over 80\% of patients seek
care at an advanced stage of the disease, leading to high mortality
rates of up to 40\% {[}8{]}. For example, data from the Yaound\selectlanguage{ngerman}é
population-based cancer registry estimates an incidence of childhood
cancers of 125/1,000,000 children, with approximately 1552 incident
cases of childhood cancers expected to occur annually {[}9{]}. Despite
this incidence level, in 2018, the pediatric oncology unit of the Mother
and Child Centre of the Chantal Biya Foundation {[}MCC/CBF{]} (The
Reference Pediatric Hospital located in Yaoundé, Cameroon) recorded only
150 new cases of childhood cancer11Pediatric Oncology Unit Service
Register, Mother and Child Center/Chantal Biya Foundation, representing
below 10\% of the expected number, which is likely an underestimation of
the true value.

Data on the management of childhood cancers in Cameroon are warranted
for policy implementation and prioritization of expenditures. Therefore,
this study sought to investigate the key obstacles to optimal pediatric
cancer care in the two functional oncology services in Cameroon.
Specifically, we aimed to describe pediatric cancer service
availability, human resource capacity involved in pediatric cancer care,
treatment completion, patient education and disclosure as well as data
management system for pediatric cancers.

\section*{Methods}

{\label{methods}}

This cross-sectional descriptive study was conducted in July 2020 in
Cameroon. Cameroon is a bilingual and multicultural Central African
country, with about 28 million inhabitants in 2022 across the countries
10 administrative regions {[}10{]}. The country healthcare system has a
pyramidal structure, organized into three levels: i) the peripheral
(operational) level, which is at the base of the pyramid. It consists of
an extensive network of district hospitals (DH), sub-divisional
hospitals (CMA) and Integrated Health Centers (IHC), which are spread
across the country's 10 regions {[}11{]}.; ii) the intermediate level,
which consists primarily of regional hospitals (RH) and Regional
Hospital Centres (RHC), whose technical platforms are higher than that
for district hospitals; iii) the central level, which is at the top of
the pyramid. It consists of specialized reference hospitals, including
General Hospitals (GH) and Central Hospitals (CH) as well as well as
administrative structures that are responsible for developing,
regulating, and coordinating health strategies. Figure 1 shows the
distribution of these facilities across the countries 10 regions.

Table 1: Distribution of Health Facilities in Cameroon by type and by
region\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\textbf{Region} & \textbf{GH} & \textbf{CH} & \textbf{RHC} & \textbf{RH}
& \textbf{DH} & \textbf{CMA} & \textbf{IHC} &
\textbf{Total}\tabularnewline
\midrule
\endhead
\textbf{AD} & 0 & 0 & 1 & 1 & 12 & 17 & 154 &
\textbf{185}\tabularnewline
\textbf{CE} & 2 & 8 & 0 & 1 & 49 & 95 & 1,429 &
\textbf{1,584}\tabularnewline
\textbf{ES} & 0 & 0 & 1 & 1 & 21 & 21 & 220 &
\textbf{264}\tabularnewline
\textbf{EN} & 0 & 0 & 1 & 3 & 30 & 27 & 384 &
\textbf{445}\tabularnewline
\textbf{LT} & 2 & 2 & 0 & 2 & 53 & 78 & 1,159 &
\textbf{1,296}\tabularnewline
\textbf{NO} & 1 & 0 & 1 & 1 & 16 & 9 & 287 & \textbf{315}\tabularnewline
\textbf{NW} & 0 & 0 & 1 & 1 & 30 & 32 & 346 &
\textbf{410}\tabularnewline
\textbf{OU} & 0 & 0 & 1 & 1 & 35 & 68 & 727 &
\textbf{832}\tabularnewline
\textbf{SU} & 0 & 1 & 1 & 1 & 13 & 34 & 260 &
\textbf{310}\tabularnewline
\textbf{SW} & 0 & 0 & 1 & 2 & 32 & 26 & 276 &
\textbf{337}\tabularnewline
\textbf{Total} & \textbf{5} & \textbf{11} & \textbf{8} & \textbf{14} &
\textbf{291} & \textbf{407} & \textbf{5,242} &
\textbf{5,978}\tabularnewline
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health Center &
AD-Adamawa; CE-Center; ES-East; EN-Extreme North; LT-Littoral; NO-North;
NW-Northwest; OU-West; SU-South; SW-Southwest \textbf{G}H-General
Hospital; CH-Central Hospital; RHC-Regional Hospital Center; RH-Regional
Hospital. CMA-Sub-divisional Hospital; IHC-Integrated Health
Center\tabularnewline
\bottomrule
\end{longtable}

Of the nearly 6,000 facilities in the country, just two hospitals
provide oncology services for pediatric patients. These include the
Mother and Child Centre of the Chantal Biya Foundation (MCC/CBF) located
in Yaound\selectlanguage{ngerman}é in the capital City and the Mbingo Baptist Hospital (MBH),
located in the Northwest region, about 360 km from the capital city of
Bamenda. The MCC/CBF is a state-owned referral and teaching hospital and
research center and offers mainly chemotherapy and palliative care for
the management of childhood cancers while The MBH is a faith-based
referral hospital and a teaching center, which offers chemotherapy,
surgery and palliative care services for both childhood and adult
cancers patients.

\textbf{Study procedure and data collection}

The questionnaire we used for the study was developed by adapting
questions from different questionnaires including, the Impact Assessment
for improving outcomes of cancer strategies developed by the government
of the United Kingdom. The adapted questionnaire was jointly reviewed
and validated in stakeholder meeting at the national committee for the
fight against cancer prior to data collection. The final questionnaire
had sections to collect information on pediatric cancer service
availability (chemotherapy, radiotherapy, nuclear medicine), human
resource capacity, chemotherapy treatment completion, patient education
and disclosure of status as well as data management. Following
administrative authorization from Cameroon's Ministry of Health (MOH),
we deployed trained data collectors to the MCC/CBF, who used the
approved questionnaire to collect the required data; however, due to
security risks in the North-West Region, these data collectors could not
visit the MBH. As a result, we sent a copy of the tool to two of the
co-authors of this paper (GMA and FT) electronically, who in turned
leveraged it to collect the necessary data. To understand reasons for
drop-out, families identified as loss to follow-up were contact traced
through phone calls and their reason for discontinuing treatment was
recorded.

\textbf{Data management and analysis}

Data collected were transferred to a secure database, cleaned, and
analysed using Microsoft Excel 2016\textsuperscript{®}. Frequencies and
percentages were used to summarize categorical variables and the output
of this analysis is presented in text, figures, and tables.

\textbf{Results}

\textbf{Common pediatric cancers}

Data from the surveyed hospitals reported that 169 cases of pediatric
cancers were diagnosed in 2019 and required chemotherapy. Figure 1 shows
the frequency of the reported cancers in both hospitals. As illustrated,
commonest cancer types in both hospitals diagnosed and treated in 2019
included Burkitt's lymphoma (39, 23\%), Lymphoblastic lymphoma (29,
17\%), non-Hodgkin lymphoma (20, 12\%), and acute lymphoid leukemia (20,
12\%). Other cancers, including nephroblastoma, neuroblastoma, and
retinoblastoma, among others were also identified but their frequencies
were low, lower than 10\% (Figure 1).

\textbf{Cancer service capacity}

Both facilities offered pediatric chemotherapy and palliative care
services. Whereas MBH offered surgery for pediatric cancers needing
surgical treatment, the MCC/ often referred this category of patient to
a surgeon or a special hospital, depending on the type of surgery
required for the cancer. In addition, neither of the facilities offered
nuclear medicine nor radiotherapy service at the time of the study.
However, it's worth noting that MBH has engaged rehabilitation works to
restore its radiotherapy services.

\textbf{Human resource capacity}

Table 2 shows the distribution of human resources for pediatric cancer
in the two hospitals. We enumerated one pediatric hemato-oncologist, one
surgical oncologist, and one medical oncologist in the surveyed
hospitals. However, there were pediatric residents working in the
hemato-oncology unit of MCC/CBF whom we did not include as specialists,
given their schedule at the unit. In addition, the Groupe Franco
Africain d'Oncologie Pédiatrique (GFAOP) offers an 18-month training
course in paediatric oncology. At the time of the assessment, one of the
current residents had completed this paediatric oncology course.
Therefore, there were three pediatric oncologists for an expected 1552
incident cases of childhood cancers annually. Furthermore, about 40\%
(18/45) of staff involved in pediatric oncology have received specialty
training in pediatric oncology. All surveyed hospitals had psychosocial
support personnel, including chaplains, teachers, trained nurses, and
volunteer staff who supported the clinicians to provide psychotherapy to
patients and their families.

\textbf{Table 2:} Distribution of human resources involved in pediatric
cancer care in two pediatric cancer hospitals in Cameroon\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Staffing}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{MCC/CBF}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{MBH}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Total}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Trained health care workers (Specialists)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Oncology Nurse\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{14}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Surgical oncologists\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{1}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Pediatric Hemato-Oncologist\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{1}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Medical Oncologist\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{1}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Residents\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{1}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Subtotal}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{6}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{12}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{18}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Other HCW involved in cancer care}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Other HCW involved in cancer care}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Other HCW involved in cancer care}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Other HCW involved in cancer care}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Nurse\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{20}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
General Practitioners\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{3}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Data Clerks\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{2}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Medical Secretary\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{2}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Subtotal}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{13}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{14}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{27}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Average cost of chemotherapy pre-treatment}

We assessed the average cost of chemotherapy, focusing on the cost
incurred during pre-treatment workup, by combining data on the cost of
pre-treatment work-up11Complete blood count, liver enzymes (serum
glutamic oxaloacetic transaminase and serum glutamic pyruvic
transaminase), creatinine, blood electrolytes, glycemia, and medical
imaging (X-Ray, ultrasound, and computed tomography scans)., as these
were the only consistent data available across the two sites. Table 3
summarizes the approximate cost of the different components of
pre-treatment work-up. Overall, the average cost for pre-treatment
work-up was \textasciitilde{}28,408 FCFA (US \$46), ranging from
\textasciitilde{}23,500 FCFA (US \$38) to \textasciitilde{}64,950 FCFA
(US \$105). We did not obtain reliable data on the cost of pediatric
chemotherapy sessions as these varied per case and per cancer type.

\textbf{Table 3:} Cost of pre-treatment work-up (10\textsuperscript{3}
FCFA)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Min (USD*)}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Max (USD)}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Average (USD)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre-treatment Laboratory Investigations}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre-treatment Laboratory Investigations}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre-treatment Laboratory Investigations}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre-treatment Laboratory Investigations}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Complete Blood Count\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3.5 (5.7)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
6.9 (11.2)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
5.3 (8.6)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
SGOT\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.0 (1.6)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
4.0 (6.5)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.5 (4.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
SGPT\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.0 (1.6)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
4.0 (6.5)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.5 (4.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Creatinine\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.0 (3.2)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.5 (4.0)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.3 (3.7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Electrolytes\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.0 (3.2)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
11.5 (18.6)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
6.8 (11.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Glycemia\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.0 (1.6)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.5 (4.0)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.8 (2.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
X-Ray\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
6.0 (9.7)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
8.5 (13.8)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
7.3 (11.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Ultrasound\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
7.0 (11.3)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
25.0 (40.5)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
16.0 (25.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
USD = United States Dollar; SGOT = Serum glutamic oxaloacetic
transaminase; SGPT = Serum glutamic pyruvic transaminase. Conversion
from FCFA to USD was done at https://www1.oanda.com/currency/converter/
on 27 December 2022\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
USD = United States Dollar; SGOT = Serum glutamic oxaloacetic
transaminase; SGPT = Serum glutamic pyruvic transaminase. Conversion
from FCFA to USD was done at https://www1.oanda.com/currency/converter/
on 27 December 2022\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
USD = United States Dollar; SGOT = Serum glutamic oxaloacetic
transaminase; SGPT = Serum glutamic pyruvic transaminase. Conversion
from FCFA to USD was done at https://www1.oanda.com/currency/converter/
on 27 December 2022\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
USD = United States Dollar; SGOT = Serum glutamic oxaloacetic
transaminase; SGPT = Serum glutamic pyruvic transaminase. Conversion
from FCFA to USD was done at https://www1.oanda.com/currency/converter/
on 27 December 2022\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Treatment abandonment}

Treatment abandonment includes failure to start treatment or treatment
dropout. Treatment dropout is defined as treatment discontinuation for
at least four weeks consecutively {[}12{]}. Of the 169 cancer cases
requiring chemotherapy, 148 (88\%) initiated chemotherapy. However,
among those that started chemotherapy, 28 did not complete the required
number of sessions, corresponding to a treatment dropout rate of 19\%.
In total, about 30\% of patients with pediatric cancer, who were
eligible for chemotherapy, abandoned their treatment. Figure 2
illustrates the pediatric chemotherapy cascade for the two hospitals.

\textbf{Primary reasons for treatment abandonment}

Among the 28 children that did not complete the required number of
sessions, we probed further to identify primary reasons What for not
doing so. Table 4 illustrates the primary reasons for treatment
abandonment among the children that started chemotherapy. As
illustrated, the leading reason was insufficient funds to pay for
chemotherapy sessions (11, 39\%). We were not able to get in touch with
9 families and so their reasons for treatment abandonment were not
identified.

\textbf{Table 4: Primary reasons for not completing chemotherapy
sessions among pediatric cancer patients}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Reasons for chemotherapy treatment abandonment} & \textbf{n} &
\textbf{\%}\tabularnewline
\midrule
\endhead
Insufficient funds to pay for treatment package & 11 &
39\%\tabularnewline
Other unspecified family decision & 5 & 18\%\tabularnewline
Preference for other treatment plans (e.g herbalist, traditionalist etc)
& 3 & 11\%\tabularnewline
Unknown reasons (could not get in touch with family) & 9 &
32\%\tabularnewline
& 28 &\tabularnewline
\bottomrule
\end{longtable}

\textbf{Patient status disclosure and follow-up}

Oncologists and oncology nurses were mostly responsible for disclosing
cancer status to patients and their families in both sites. Other staff,
including residents, psychosocial support staff and chaplains, were
occasionally involved in the disclosure process; however, we could not
ascertain whether these staff have received training on disclosure of
cancer status.

\textbf{Data Systems}

Both sites had at least one data collection tool, including a cancer
service register, monthly reporting forms, and a cancer registry.
However, data collection tools were not harmonized, and there was no
data reporting scheme for pediatric cancer in both sites.

\section*{Discussion}

{\label{discussion}}

This study describes the status of pediatric cancer services in
Cameroon, and suggests the need for considerable expansion in reach,
type, and specialization of services provided. Nearly two-thirds of
current staff in pediatric oncology services have not received prior
pediatric oncology capacity building. Pediatric chemotherapy
pre-treatment investigations are expensive for the average Cameroonian
family. As a result, about 30\% of children with cancer abandoned
treatment. In addition, the overburdened oncologists were required to
conduct patient education and disclosure of cancer status, sometimes in
combination with caregivers or parents. Regarding data management, data
collection tools were available but not harmonized at cancer sites, and
there was no systematic data reporting scheme for pediatric cancer data.
The fact that just two of the nearly 6,000 facilities in Cameroon are
offering pediatric oncology services, is an appalling finding, which
further re-iterates the negligence that these categories of patients
with curable cancers face. To us, this is clarion call to action to
address this unmet need for pediatric cancer patients- both to the
government and the international donor committee.

These findings suggest that pediatric cancer services in Cameroon need
serious and urgent expansion and modernization, which lends support to
findings from most parts of Africa. Only about 71\% of countries in
Africa had a functional national cancer control programme, with
substantial variations in cancer services within countries {[}13{]}.
Therefore, the need to address these service capacity gaps is imminent
as these will enable investments in cancer control to prevent premature
death. This can be done in a phased approach, progressively expanding
pediatric chemotherapy services to targeted regional hospitals and
similar structures across the nation, creating and integrating regional
cancer control units under the leadership of regional delegations of
public health. At the health district level, community health workers
need to be trained to identify early warning signs and rapidly detect
suspected cases through simple gestures.

Adequate human resource capacity is critical for effective and holistic
cancer management. However, surveyed cancer treatment centers lacked the
human capacity for optimal pediatric cancer care. Furthermore, the
University system does not produce sufficient oncologists to match the
escalating burden of this disease. Nearly two-thirds of staff involved
in pediatric oncology service had not undertaken specialty training in
this domain, suggesting the need to design and roll out several human
resource interventions for cancer control in the country. This may
involve instituting a system for periodically training key staff,
including pediatric oncologists, pediatric oncology surgeons, and
oncology nurses. Another entails strengthening the capacity of existing
staff by rolling out training on the early detection of common cancers
and building their capacity on essential concepts of chemotherapy and
palliative care. Improving the quality of health personnel in pediatric
treatment facilities can play a great role in children's treatment
outcomes {[}14{]}. This should include incorporating palliative into all
childhood cancer treatment facilities to meet the multidisciplinary
needs of children and their families as well as proven approaches to
disclose information to patients and their families The latter is
important because poor management of information of the disclosure
process can result into complications, grief, and poor mental health in
children and their surviving families {[}15{]}. It is also important to
implement systems to provide newly recruited staff with skills to
support cancer care and treatment effectively and rapidly. Furthermore,
there is a need for continuous human resource gaps assessments and
addressing training and retraining needs.

In this assessment, Burkitt lymphoma was reported as the most treated
pediatric cancer, representing nearly one-quarter of all pediatric
cancer patients in Cameroon. This highly aggressive and fast-growing
tumour has been previously described as the most common childhood
cancer, especially in tropical African countries where malaria is
holoendemic {[}16{]}. Recent evidence suggests a strong association
between malaria and Burkitt lymphoma {[}16, 17{]}. However, whether this
association is causal remains uncertain, partly because data on the
epidemiology of Burkitt lymphoma in sub-Saharan Africa are rare even
from the most affected countries like Malawi, Uganda, Nigeria, and
Cameroon. In addition, over 80\% of Burkitt lymphoma is associated with
the Epstein-Barr virus, and Burkitt lymphoma is predominant in boys and
children aged 5-9 years.

We found a high abandonment rate for pediatric cancer treatment of about
30\%. Specifically, about 12\% of children who needed chemotherapy did
not get it, and approximately 20\% of those on chemotherapy did not
complete the required treatment sessions. High treatment abandonment
rates have been reported in sub-Saharan African countries ranging from
15-60\%. The reasons for treatment abandonment are multifactorial,
including a high cost of care, poor awareness, long distances to
treatment centers, absence of health insurance coverage, the high
toxicity of treatment, long chemotherapy sessions, absence of social
support, and fear of the unknown {[}18--20{]}. Inequities in treatment
options are a major factor in the disparity in treatment between
developed and developing, yet this is under-researched and receives
little attention when reporting the Sustainable Development Goals
{[}21{]}. In addition, treatment abandonment rates are associated with
failure and poor survival rates {[}19{]}. Therefore, there is a need to
improve access to chemotherapy by harmonizing protocols, upgrading the
technical platforms of specialised structures, ameliorating forecasts,
and strengthening financial resource mobilization for procuring cancer
products.

Cancer status was mostly disclosed by already overburdened oncologists
and oncology nurses in most instances, despite the availability of staff
who could handle patients' status disclosure if empowered with the
appropriate training. Organizing capacity-building sessions on status
disclosure for relevant hospital staff and community health workers
could go a long way to improve pediatric cancer patient education,
tracking and follow-up.

Data collection and reporting are critical for informed decision-making
for enhanced health services. Although both surveyed facilities had data
collection tools, data collection was not harmonized in terms of tools
for collection and time for collection. In addition, there was no scheme
in place for reporting pediatric cancer data to regional and central
levels for policymaking. This significantly hinders research and
development, warranting developing a harmonized national data collection
tool with selected variables and indicators. In addition, the said
indicators could be customized into the national health information
software 2 (DHIS2). Furthermore, the data tools could be leveraged in
the long term to build a functional pediatric cancer registry.

\section*{Conclusion}

{\label{conclusion}}

We found that optimal pediatric oncology care in Cameroon is compromised
by limited-service availability and inadequate human resource capacity.
In addition, a high proportion of children eligible for chemotherapy
abandoned treatment due to high cost of treatment package. Furthermore,
the lack of harmonization of data collection tools and the absence of a
standard data reporting mechanism hinders informed decision-making.

Our study suggests an urgent need to expand pediatric oncology case
identification services and build human resource capacity on treatment
initiation, patient education and tracking to minimize dropout rates. In
addition, harmonizing pediatric cancer data collection tools and
designing a reporting scheme will facilitate the creation of a pediatric
cancer registry. In addition, synchronizing pediatric cancer data with
the national health system software will increase the visibility of
pediatric cancer burden across the nation. Once the data has been
collected and centralised, sufficiently equipped technical teams must be
put into action to develop interventions with a high public health
impact. Finally, there is imminent need for the creation of a nation
cancer institute which will bring together cancer specialists
(oncologists, radiologists, surgeons etc) in a common technical
platform.

\section*{References}

{\label{references}}

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\selectlanguage{english}
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\end{document}

