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Burkitt’s Lymphoma- Malaria, poverty fuel children cancer

By Vision Reporter

Added 25th October 2009 03:00 AM

SHE has been residing at the Mulago Cancer Institute for three months, attending to her one-year-old ailing son and hoping that somebody will be discharged so she can get a bed.

SHE has been residing at the Mulago Cancer Institute for three months, attending to her one-year-old ailing son and hoping that somebody will be discharged so she can get a bed.

By Irene Nabusoba

SHE has been residing at the Mulago Cancer Institute for three months, attending to her one-year-old ailing son and hoping that somebody will be discharged so she can get a bed.

Nonetheless, Janet Alomo has taken baby Simon away from the biting night cold on the veranda, to a relatively warmer space in the ward’s corridors.
The cancer institute houses over 200 children that are diagnosed with Burkitt’s lymphoma, a paediatric form of cancer, annually.

“Fortunately enough, if diagnosed early, this is one cancer that is sensitive to chemotherapy (cancer treatment),” says Dr. Fred Okuku, an oncologist at the institute.

“Before aggressive therapeutic programmes were started, many children lost their lives to Burkitt’s Lymphoma. With chemotherapy and prophylaxis (prevention), the survival rate is at least 60%.

Patients who report early have a survival rate of 90%. But like the situation is in Uganda, most cancers are reported late with poor treatment and Burkitt’s Lymphoma is no exception,” Okuku regrets.

History of Burkitts lymphoma
Okuku says in 1956, Dennis Burkitt, a British surgeon working in central Africa, described an unusual type of lymphoma common in children. “This is how the cancer came to be known as Burkitt’s lymphoma,” says Okuku.

“Burkitt expanded his research to Mulago National Referral Hospital, consequently founding the Burkitt’s Lymphoma Institute in 1967, which is the National Cancer Institute today.

“That is why last year’s international conference on Burkitt’s lymphoma and related lympho disorders was held in Kampala to commemorate this discovery,” Okuku explains.

Causes
The cancer is caused by the Epstein-Barr (EB) virus. “If you have this virus in the system and get frequent bouts of malaria with poor treatment, it leads to this cancer. This, together with poor hygiene, blows out the cancer. That is why it is referred to as a cancer of the people with a low social economic status.”

Internet site www.cancerbackup.org reveals that the cancer occurs when children’s B-lymphocytes (jaw area lymph nodes) are infected with the EB virus.

While the infection is common and usually causes no long-term problems, according to the site, in Central Africa, many of the children had chronic malaria infections, which reduced their resistance to the virus.

“In some cases, this allowed the virus to change the infected B-lymphocytes into cancerous cells, leading to the development of the lymphoma.”

“This classical African or endemic type of Burkitt’s lymphoma usually affects the jawbone. It can spread to the nervous system, damaging the nerves and causing weakness or paralysis. It may also affect the lymph nodes or bone marrow,” the site adds.

An online encyclopedia generalises Burkitt’s lymphoma as a cancer of the lymphatic system, particularly the B lymphocytes.

“It is the most common malignancy of children in this area. The disease characteristically involves the jaw or other facial bones, although it may extend to other internal organs like the liver, kidney or breast,” the site reveals.

Symptoms
Burkitt’s lymphoma is one of the fastest growing malignancies in humans, with a very high growth fraction.

“It most often involves the maxilla or mandible jawbones. The commonest symptom is loose teeth, which parents mistake and remove with no improvement only to realise growths in the mouth, which if medical help is not sought, may obstruct the airway.

It is normally a huge mass in the mouth, foul smelling, may even block the airwaves, besides loose surrounding teeth,” he says.

“The mean age is seven, but the cancer affects children up to about 11 years. Patients most often present with swelling of a jaw or other facial bones, loosening of the teeth and swelling of the lymph nodes, which are non-tender and rapidly growing in the neck or below the jaw.

Abdominal presentation is less common,” Okuku says. Other symptoms include unexplained high temperatures, sweating at night, loss of appetite and weight.

Challenges
Most patients cannot afford transport costs and treatment. While treatment is supposed to be free at the cancer institute, the cost of a course of cyclophosphamide, doxorubicin, vincristine and prednisolone — the recommended treatment, is $450 (about sh950,000).

The situation has been worsened by the fact that most cancers are reported in advanced stages, which means life-long treatment, yet the institute has only 60 beds.

Some children share the ward with adults. “We need more room. We fixed baby cribs in the wards to create more space. Some people give up and return to their homes to die,” a survivor volunteering at the ward says.

Dr. Jackson Orem, the director of the National Cancer Institute, Mulago Hospital says: “The current bed capacity at Mulago is small and the patients are overcrowded. There are only two wards with 30 beds each.

“We have been forced to fix more beds in the wards, but the numbers are still overwhelming,” he says.

Government funding has not made it any better. The annual budget to Mulago is sh5b yet the institute alone needs sh6b a year to effectively operate. “We need at least sh6b for drugs because salaries and utilities are paid by the Government.

But we only receive sh150m,” he says. “Yet the majority of parents with children suffering from Burkitt lymphoma are subsistence farmers,” Orem says.

Orem says there is need for public education and training of health workers to improve awareness of Burkitt lymphoma for early referral and successful treatment.

“If we spray DDT and kill with mosquitoes, we shall do away with not only malaria, but also Burkitt’s lymphoma.”

A parent’s testimony
Alomo has been camped at the ward for the last three months and plans to stay put until baby Simon’s treatment course is over.

“It is expensive to go to Soroti and back,” Alomo says. “Some of my colleagues have gone back but have failed to return. Eventually, the patients die.

“My husband agreed to stay home and look after our other children, while I tend to Simon,” she says, rocking him in her arms.

“I am happy here. I depend on handouts from well wishers, but that is ok. My Simon is almost well. He cannot eat yet he continues to vomit. It is one of the bad days, but I am hopeful. The doctor says Simon is doing well and will be fine,” she says.

HOW COMMON IS THE CANCER?
The report, Kenya and Uganda grapple with Burkitt lymphoma, published in the Lancet Oncology, a global prestigious online journal, says the number of cases of Burkitt lymphoma reported at health units in these countries is increasing.

“Burkitt lymphoma represents half the number of childhood tumours treated at national referral hospitals in Kenya and Uganda. However, there are no statistics on the actual disease burden in either country, which further undermines efforts to address the problem,” the publication says.

According Dr. Jackson Orem, the director of the National Cancer Institute at Mulago, the facility handles an average of 1,000 new cases every month, 600 of them children.

There are also about 9,000 continuing adults with about 4,500 children.
“Over 50% of the paediatric case load with a tumour has Burkitt lymphoma,” Orem says. “A total of 200 children are diagnosed with Burkitt lymphoma every year.

Most of them are from the eastern region, particularly Pallisa, Budaka, Kumi, Soroti and Mbale. Patients from northern Uganda can be handled at Lacor Hospital, West Nile-Kulva Hospital and western-Mbarara Hospital.

Burkitt’s Lymphoma- Malaria, poverty fuel children cancer

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