Journal of Pharmacy and Pharmacology 10 (2022) 97-104

doi: 10.17265/2328-2150/2022.03.005
D DAVID PUBLISHING

Paediatric Cancer Care in Abakaliki South-East Nigeria:

Challenges and Outcome

Udechukwu Ngozi Patricia1, Ukoh Uchechukwu Chukwuebuka1, Nwagha Theresa Ukamaka2 and Nwokoye
Ikenna Chidiebele1
1. Department of Paediatrics, Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), Ebonyi State, Nigeria
2. Department of Internal Medicine, AEFUTHA, Ebonyi State, Nigeria

Abstract: The care of children with malignancy is almost always a feat and is even more difficult in resource-poor settings such as
our country Nigeria where several factors present as challenges as seen in other countries of sub-Saharan Africa. In this study, we
present our experience in AEFUTHA, over a six-year period. This study aimed at finding out the current prevalence, outcomes and
challenging issues leading to poor outcomes. This retrospective study spanned from January 2012 to December 2017. Information
was extracted from the patients’ case notes using a structured data proforma. Children aged 17 years and below who satisfied the
inclusion and exclusion criteria were studied and the sample size was 68. In our study, the prevalence of paediatric malignancy is
2.0%. The outcome was generally poor with a mortality rate of 30.9%, and 60.3% having abandoned treatment at various stages of
management. The top-ranking challenges noted included diagnostic problems and late presentation accounting for 19.8% and 17.3%
respectively and, poverty and lack of effective treatment and drugs representing 16.0% each. We conclude that there is a need to
adopt a multifaceted approach to tackling these challenges to improve outcomes.

Key words: Paediatric, malignancy, challenges, outcome, resource-poor-setting.

1. Introduction Hospital, our centre stressed in a local report released

more than 10 years ago that backward diagnostic
The care of children with malignancy in Nigeria, as
facilities and poverty are the main challenges [6],
in any other country in the developing world, presents
while reports from other parts of southern Nigeria also
multiple challenges such as poor diagnostic capabilities.
stressed the challenges caused by backward diagnostic
Poor socio-economic status, late presentation, and
facilities, poverty and backward reporting. High
ignorance [1, 2]. The limited resources, facilities and
default rate and low education level of parents are the
trained personnel as seen in Low and Middle-Income
reasons for bad results [7, 8]. In Northern Nigeria,
Countries (LMIC) also contribute to less than standard
Offiong et al [2] reported poverty, ignorance, and
oncologic care [3]. The burden of the disease is
lack of a cancer research unit as the main contributory
equally high with mortality rates ranging from
factors to poor outcomes.
21.7%-59% [2, 4, 5]. With the advances and progress
Similarly, reports from Uganda and Kenya highlighted
made in paediatric cancer care in high-income
ignorance, poverty, late presentation, and large family
countries, these aforementioned challenges create a
size as major constraints in paediatric cancer
big disparity in disease outcomes between the
management [9, 10]. In Zambia, poor access due to
high-income, and LMIC.
the long distance to health facilities, low maternal
Alex Ekwueme Federal University Teaching
education, and discharge against medical advice were
the causes of the poor outcome reported [11].
Corresponding author: Ukoh Uchechukwu Chukwuebuka,
FMCPaed, MB, BS, research fields: paediatric oncology, paediatric
In high-income countries such as the United States
emergency, general paediatrics. Email: ukohuc@yahoo.com. (US) and Canada, where the outcome is better, the
98 Paediatric Cancer Care in Abakaliki South-East Nigeria: Challenges and Outcome
emphasis is on reducing the challenges of patient
management to optimize the outcome and improve
five-year survival beyond 80% [12].
Interventions proffered to address the challenges of
childhood cancer care by Israel et al [13] were
advocacy and education of health workers,
twinning/partnership with centres in high-income
countries to improve care and survival, forming
regional collaborative groups of childhood cancer care
centres, development of care guidelines, and capacity
building.
It is hoped that the New National Agency for
Cancer Control working with the same principle as the
National Agency for the control of Acquired Immune
Deficiency Syndrome (AIDS) using multi-stakeholder
public-private partnerships to provide free or highly
subsidized cancer medicines will be of great relief
when it becomes operational [14]. North East Brazil, a
resource-poor setting was able to improve five-year
event-free survival from 32% in the early period of the
study, to 47% in the middle period by using the
treatment protocol, then to 63% in the recent period by
further addition of management of patients in a
dedicated oncology unit staffed by trained personnel.
The study periods were 1980-1989, 1994-1997 and
1997-2002 representing early, middle and recent
periods in that other [15]. This feat certainly portends
hope for Nigeria. Also in Ivory Coast, Yao. et al [16]
acknowledged improvement in the management of
children with cancer from collaborations within the
Franco-African Group of Paediatric Oncology.
Children with cancer face enormous difficulties in
accessing health care in Nigeria. [2] Many children
cannot be offered any effective treatment due to
complications in their growth and development.
Co-morbidities like infection and malnutrition further
complicate treatment [17]. Earlier study done in this
city, Abakaliki 14 years ago reported a poor outcome
of Paediatric cancers [6], and this has persisted. This
brings the need to repeat this study to find out the
current prevalence, the outcome and challenging
issues leading to poor outcomes.
2. Patients and Methods
2.1 Study Setting
Ebonyi State is in the South-East geopolitical zone
of Nigeria with an estimated population of 2,504,003
for the year 2011 of which 57.4% are people under 18
years of age [18]. AEFUTHA, the study centre is a
product of a merger between the former Federal
Medical Centre Abakaliki and Ebonyi State
University Teaching Hospital in December 2011 to
give the Federal University Teaching Hospital, which
was renamed AEFUTHA in 2019. This study was
carried out in the Department of paediatrics of the
AEFUTHA, which is a tertiary hospital in Ebonyi
State and serves as a referral centre for patients within
and outside the State.
Chemotherapy protocols used were from
established guidelines (National Guideline) and Unit
Protocol. The cost of chemotherapy, other supportive
care and blood component therapy were from out of
pocket expenses.
2.2 Study Design
This was a retrospective study and spanned from
January 2012 to December 2017, being a six-year
period.
2.3 Characteristics of the Participants
Being a retrospective study, all cases of children
with suspected cancer admitted to the paediatric
oncology unit over a six-year period from January
2012 to December 2017 were reviewed. Ethical
approval was obtained from the Research and Ethics
Committee of AEFUTHA, number:
FETHA/REC/VOL1/2017/480.
2.4 Inclusion Criteria
Children aged 17 years and below diagnosed with a
cancerous condition in this institution within the study
period were included in the study.
 Paediatric Cancer Care in Abakaliki South-East Nigeria: Challenges and Outcome 99

2.5 Exclusion Criteria analyzed using Statistical Package for Social Sciences
(SPSS) version 20. Results were presented using tables
Children who had been diagnosed with cancer and
and charts. The Chi-Square test was used to test for
had begun treatment in another facility before being
significance. P values < 0.05 were considered significant.
transferred to this institution were excluded.

2.6 Data Collection

3. Results
The total number of patients admitted in the
The patients were identified from the admission
paediatric ward between January 1st 2012 and
register. Detailed information was extracted from their
December 31st 2017 was 4,552. Ninety (1.98%) of
case files and paediatric cancer register using a structured
them were admitted and managed for cancer, which
proforma. The variables studied included demographics,
included 52 males (57.8%) and 38 females (42.2%)
duration of symptoms before presentation, diagnosis,
with a male-to-female ratio of 1.4: 1. Of the 90
stage of disease at diagnosis, methods of diagnosis,
managed for cancer, we had sufficient data for 68
treatment administered and outcome. The socioeconomic
cases made up of 39 males and 29 females. Their ages
class classification was according to Olusanya et al.
ranged from four months to 15 years with a mean age
[19]. Tumor metastasis was identified clinically and by
of 7 ± 4.57 years. Patients aged 5 years and younger
imaging studies of X-ray, CT scan, ultrasound scanning
accounted for 52.9% (Table 1). The overall annual
and other investigations like cerebrospinal fluid (CSF)
distribution for paediatric cancer was 2.0%, with the
analysis. Sufficient data include cases that have
highest value seen in the year 2012 (Table 2).
biodata, demographics, and clinical details including
final diagnosis, treatment and outcome. Patients who 3.1 Duration of Illness
were not seen four weeks after the last scheduled
follow-up date were considered lost to follow-up. Five patients (7.4%) presented beyond 30 weeks of
the onset of symptoms, two of those have had
2.7 Statistical Analysis symptoms for up to one year. The mean duration of
Data were entered into an excel spreadsheet and symptoms before presentation was 14 ± 7.98 weeks.

Table 1 Patient Demographics.

Variables Frequency Percentage
Age (yr)
<1 3 4.4
1-5 33 48.5
6-10 13 19.1
11-15 18 26.5
> 15 1 1.5
Gender
Male 39 57.4
Female 29 42.6
Place of Residence
Rural 40 58.2
Urban 28 41.2
Family Social Class
Low 40 58.8
Middle 25 36.8
High 3 4.4
100 Paediatric Cancer Care in Abakaliki South-East Nigeria: Challenges and Outcome

Table 2 Annual distribution of childhood cancer.

Year Total admissions for the year With malignancy No./ (%)
2012 675 19 (2.8)
2013 1071 17 (1.6)
2014 510 9 (1.8)
2015 540 12 (2.2)
2016 720 16 (2.2)
2017 1036 17 (1.6)
Total 4552 90 (2.0)

Only 14 (20.6%) of patients presented before

metastasis, while 54 (79.4%) had advanced metastatic
disease on presentation (Table 3).
Figure 1 shows the different cancer types, though
NHL (19.1%) takes the lead for individual tumours, but
the embryonic tumours including Rhabdomyosarcoma,
Nephroblastoma, Retinoblastoma and Neuroblastoma
are the next four most frequent and combine to 51.5%.
3.2 Treatment Outcome
Four patients (5.9%) completed treatment, but three
were lost to follow-up, the remaining one had
achieved five-year survival. There was an overall
mortality rate of 30.9%, while up to 55.9% abandoned
treatment at various stages of management; these are
shown in Table 4.

Table 3 Duration of illness before presentation.

Patient’s diagnosis
Duration (weeks)
WT RMS NHL RB NB AL OTHERS TOTAL (% age)
0-10 4 4 8 3 0 3 4 26 (38.2)
11-20 2 3 3 2 3 3 5 21 (30.9)
21-30 3 2 2 1 2 1 5 16 (23.5)
> 30 1 2 0 1 0 0 1 5 (7.4)
Total 10 11 13 7 5 7 15 68
WT – Wilm’s Tumor, RMS – Rhabdomyosarcoma, NHL- Non-Hodgkin Lymphoma, RB – Retinoblastoma, NB – Neuroblastoma,
AL – Acute Leukaemia. Others: Hodgkin lymphoma, Teratoma, Chronic Myeloid Leukaemia, Langerhans Cell Histiocytosis, Basal
Cell Carcinoma, Renal Cell Carcinoma and Yolk Sac tumour

Table 4 Treatment outcome for the cancers.

Outcome
Diagnosis Completed treatment Still on treatment Abandoned treatment Died Referred Total
NHL 2 0 8 3 0 13
RMS 0 0 9 2 0 11
WT 1 0 6 3 0 10
RB 0 0 3 4 0 7
NB 1 0 4 0 0 5
AL 0 0 2 5 0 7
CML 0 0 1 1 1 3
Teratoma 0 1 1 0 1 3
HL 0 0 2 2 0 4
Others 0 0 2 1 2 5
Total 4 1 38 21 4 68
Percentage 5.9 1.5 55.9 30.9 5.9 100.1
NHL- Non-Hodgkin Lymphoma, RMS – Rhabdomyosarcoma, WT – Wilm’s Tumor, RB – Retinoblastoma, NB – Neuroblastoma,
AL – Acute Leukaemia, CML – Chronic Myeloid Leukaemia, HL – Hodgkin lymphoma, Others: Langerhans Cell Histiocytosis,
Basal Cell Carcinoma, Renal Cell Carcinoma and Yolk Sac tumour
 Paediatric Cancer Care in Abakaliki South-East Nigeria: Challenges and Outcome 101

Table 5 Challenges involved in the paediatric cancer management.

s/no Challenges Percentage (%) Frequency*
1 Diagnostic problems 19.8 16
2 Late presentation 17.3 14
3 Poverty 16.0 13
4 Lack of effective treatment and drugs 16.0 13
5 Lack of trained manpower 11.1 9
6 Drug intolerance/reaction 8.6 7
7 Ignorance and cultural beliefs 6.2 5
8 Interruption of treatment by industrial action 3.7 3
9 Self medication 1.2 1
Total 99.9 81
*some patients had more than one reason.

2.9
4.4
4.4 7.4 19.1
4.4

5.8 17.1
7.4

10.3 16.2

Non Hodgkin Lymphoma

Rhabdomyosarcoma

Nephroblastoma

Retinoblastoma

Neuroblastoma

Acute Lymphoblastic Leukaemia

Acute Myeloid Leukaemia

Chronic Myeloid Leulaemia

Teratoma

Hodgkin Lymphoma

Others: Langerhans Cell Histiocytosis, Yolk Sac Tumor, Basal Cell Carcinoma, Renal Cell Carcinoma, Primary Liver Cell
Carcinoma

Fig. 1 Frequency distribution of the different cancer types.

The case that was still on treatment had a bad type

3.3 Challenges in Paediatric Cancer Care
of sacrococcygeal tumour (Type IV) that was complicated
by bladder outlet obstruction, hydronephrosis and Poor diagnostic capability constituted 19.8% and
urethral stricture. consisted of lack of facilities and delays due to limited
102 Paediatric Cancer Care in Abakaliki South-East Nigeria: Challenges and Outcome
resources and manpower. Other major challenges
involved were late presentation, poverty and
non-availability of effective treatment drugs, see table
5. The interruption of treatment by workers strikes in
two consecutive years and self-medication were the
least.
4. Discussion
The prevalence of 2.0% in this index study is higher
than 0.14% recorded over 10 years ago by Nnebe and
Onwasigwe in this centre [6]. This is probably due to
increased awareness and improvements in diagnostic
facilities, yet it is lower than reports from other parts
of Nigeria. [20]. The lower value in this index study
may be likely due to under-diagnosis as the other
centres referred to are more advanced with better
diagnostic facilities. The value in this study is
however higher than that obtained at Nnewi, Nigeria
[21]. This study did not show any annual variation in
the incidence of paediatric malignancy as were the
cases in Nnewi [21] and Cote d’Ivoire. [16]. The
reduction in incidence in 2014 and 2015 were due to
successive industrial actions by health care workers in
2014 and 2015.
The male to female ratio of 1.4:1 obtained in this
study is similar to reports from various parts of
Nigeria [22-24] and other parts of Africa [16].
In this study, the majority of patients were five
years and below. This is similar to the reports from
other centres in the country [20, 24, 25] for the same
age group, but differed from other reports including
Sagamu [7], Cote d’Voire [16] that had higher age
bracket (5-9 years). It is important to mention that in
this report and in those that had similar peak ages of
occurrence, the most common tumour types are
embryonic tumours. There is a high incidence of
embryonic tumours, which is known to be common in
this age group, while lymphomas and leukaemia
occurred more commonly in those with the higher age
bracket.
The majority of patients in this study belong to the
low socio-economic group, which is consistent with
findings from Ife and Kano [20], but differs from Port
Harcourt [24] where the middle class constituted the
majority. The prevalent socio-economic class noted in
this study reflects the general economic situation in
this environment, the majority of residents are peasant
farmers and come from rural settings; in addition,
most of the upper class would opt-out at the early
stages of diagnosis to more advanced centres for
continuation of management. In this study, most
patients belong to the lower class, which is a serious
problem, because it means that in an environment
where the cost of treatment is mostly at their own
expense, these patients may not put forward the
financial needs of investigation, diagnosis, treatment
and management. Although more of our patients come
from rural settings, it is still below the known level of
rural-urban population disposition in Ebonyi state
which is 70-75%: 25-30% (rural: urban ratio) [18].
This implies that quite a good number of children
affected with cancer in the rural settings are not able
to access care from the tertiary institution available.
In this study, the median duration of symptoms
before presentation was 14 weeks and up to 79.4% of
our patients presented with metastasis, these being
indicators of late presentation are higher than reports
from Port-Harcourt [24], however, a similar
proportion of patients presented with metastasis in the
study from Ibadan [8]. The majority of patients come
from remote rural areas that are far from the tertiary
centre. Such patients may have to pass through some
bottlenecks including patent medicine dealers, herbal
and traditional healing areas, primary and secondary
care centres before reaching the tertiary centre that is
usually situated in the urban. Most patients belong to
the lower socio economic class, this group is more
likely to have financial constraints, to be ignorant,
with poor health seeking behaviours, and to have
abnormal beliefs as to the causes of sickness, and
these would make them present late with subsequent
poor outcome.
 Paediatric Cancer Care in Abakaliki South-East Nigeria: Challenges and Outcome
In this study, 48.5% received chemotherapy alone,
while 26.5% had surgery and chemotherapy. Our
findings are similar to the study by Utuk and Ikpeme
[22]. Chemotherapy appears to be the commonly
available treatment form and the modality used in all
stages of the disease. It is often initiated, though the
courses may not always be completed due to financial
constraints. Surgery was also commonly available in
our centre thus was provided, but the majority of
patients had metastasis on presentation, negating the
use of this service. Supportive treatment is protean
and was used by all patients at one time or the other.
The high default rate and poor rate of completion of
treatment noted in this study are worrisome. The high
default rate is similar to the findings from other
studies [22, 24, 25]. This high default rate could be
due to financial constraints obviating continuation of
treatment as funding is mainly out-of-pocket, burn-out
syndrome on the part of the caregivers, not perceiving
obvious improvement in condition in the immediate
time despite ongoing treatment, the misconception of
the disease as a spiritual affliction thus not amenable
to orthodox medication or even not curable. It would
be expected that most will eventually be taken home,
or to spiritual or traditional healers, eventually, these
would end in fatalities. The mortality rate (30.9%) is
high. This mortality rate compares with the finding
from ABU Zaria [25], but is lower than figures from
Ibadan [5] and PH [24], but is higher than finding
from Abuja [2], it is poor. This poor outcome is likely
due to the numerous challenges we encountered in the
management of these cases including, diagnostic
difficulties, late presentation, poverty and
inaccessibility of drugs.
The main challenges to management identified in
this study are as follows: diagnostic problems, late
presentation, poverty and non-availability of treatment
drugs. These are not very different from the previous
report from this centre [6] and is similar to the
findings by Utuk and Ikpeme [22] who noted
non-availability of drugs, burn-out syndrome and late
103
presentation as major challenges. Abiola et al [28]
noted in their study that diagnostic problems ranked
highest among other challenges just like in this study.
The reasons for these challenges are obvious and are
linked to the general problems of the health
infrastructure in sub-Saharan Africa, manifesting as
scarcity of diagnostic facilities and lack of specialized
manpower; as well as issues bordering on literacy
level and economic power of the caregivers. The
consequences of these challenges are obvious.
5. Conclusions
The current prevalence of paediatric malignancies
in the study centre is 2.0%, which is a several-fold
increase from that obtained 13 years ago. The
outcome has remained poor as in other centres in the
country and reflects the numerous challenges
encountered in management; abandonment of
treatment was top on the list.
The above underscores the need to adopt a
multifaceted approach to address this: these include
embarking on massive public awareness campaigns,
provision of health insurance and making it to cover
paediatric oncology management, training of staff in
newer modalities for investigation and management as
well as provision of current diagnostic facilities.
Exploring other modalities such as the development of
regional cancer centres and twinning programs could
be of help.
Limitations
Being a retrospective study, information retrieval
posed challenges as seen that up to 22 out of 90
(24.4%) of our cases were excluded from the study
due to missing details concerning the patients.
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