Impact of Capacity Development Program on Outcomes for Pediatric Hematologic Malignancies in Tanzania
Authors: Schroeder Kristin , Rizzieri Tyler , Robles Joanna , Sued Hillary , Scanlan Patricia , Mafwimbo Judith , Maxmilian Mastidia , Kamanga Jacqueline , Masalu Nestory , Chao Nelson J. 
Published: November 2019

Background:
Globally, over 400,000 children are diagnosed with cancer each year, with hematologic malignancies being the most common diagnosis. However, there is a 60% survival gap between high income and low to middle income countries. Causes of this disparity are multifactorial and require comprehensive capacity development to improve outcomes. In 2014, a twinning program was started between Duke University and Bugando Medical Centre (BMC) in Mwanza Tanzania, focused on the development of treatment capacity for pediatric hematologic malignancies. We report on the program development and impact on outcomes for leukemia.
Methods:
Key stakeholder interviews were completed at BMC to identify areas for capacity development. A Duke University pediatric hematology/oncology faculty member spends 6 months per year on site to provide training and clinical care. Capacity development was completed through a step-wise approach based on identified needs, with one new area of focus per year. Outcome evaluation includes 1-year overall survival by diagnosis and year.
Results:
Stakeholder identified needs included development of a patient registry for monitoring, reducing cost of care, and improving provider knowledge about pediatric cancer. In 2014 the partnership established a cancer registry for outcome monitoring, and provided medical and laboratory training on the resource adapted diagnostic and treatment protocols for hematologic malignancies. In 2015, partnerships with local non-profit organizations provided chemotherapy and diagnostic testing at no cost to the patients. In 2016, the focus was on providing social support through the use of a patient navigation program and provision of local housing during treatment; in 2017 formalized treatment collaboration between BMC and the Tanzanian National Pediatric Hospital (MNH) was established. Additional local non-governmental support allowed for the transfer of patients between hospitals and care coordination.
New pediatric cancer diagnoses at BMC increased from 100 in 2014 to 170 in 2018. From 2014-2018, leukemia represented 5-17 % of total cases, and lymphomas 20-30%. 1-year overall survival for ALL was 0% prior to 2016, and an average of 56% for 2016-2018. AML 1-yr OS remained 0% over the 5-year period. CML 1-yr OS increased from 0% in 2014-2015 to 25% in 2016-2018.
From 2017-2018, 38% of patients diagnosed at BMC received national care coordination with 13% of these patients receiving part of their treatment plan at MNH.
Discussion
Despite increased training and reduced treatment costs, social support through patient navigation and a structured treatment collaboration were critical to improved outcomes for children with hematologic malignancies. These should be a priority for the development of future pediatric cancer programs in low resource settings. Additional focus on myeloid malignancies is needed to identify potential areas for outcome improvement.

Disclosures
No relevant conflicts of interest to declare.