Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Pediatric Cancer: Integrating referral systems

Author(s) Ramesh Menon1, R.K Marwaha2, Shashidhara Jayappa3.
Affiliation(s) 1Dept of Paediatrics, Institute of Maternal and Child Health, Govt Medical College, Calicut, Kerala, India, 2Dept of Paediatric Haematology and oncology, PGIMER, Chandigarh, India, 3Dept of Paediatrics, Institute of Maternal and Child Health, Govt Medical College, Calicut, Kerala, India.
Country - ies of focus India
Relevant to the conference tracks Health Systems
Summary There is no systematized referral path for centralized care for children with cancer in India which adversely affects outcome. We undertook a questionaire based survey of patients/ health care seekers in this group (children < 18 years of age) who used a tertiary care centre unit in North India ( PGIMER, Chandigarh). This study attempted to tease out the section of maximum delay in the existent variety of paths taken by health seekers among cancer patients, patient delay (symptom- contact) and system delay (contact- diagnosis) were analysed separately. Over a period of one year data was collected the saliant findings were the symptom- contact delay was 2 to 3 days and the contact- diagnosis delay was 27 to 40 days.
Background Estimated number of new cancers diagnosed in India every year is 700,000 to 900,000. The geographic, socioeconomic, educational and health system inequalities in cancer treatment, in children, have only now begun to be addressed. This study was designed to assess referral patterns of children with haematological malignancies (HM) in Northern India.
Objectives To identify the modifiable factors causing delay in the early referral of children with Haematological malignancies and to quantify the relative significance of the factors analysed.
Methodology In the period between the months of October 2001 and November 2002, based on a predesigned performa, parents/guardians
of children with haematological malignacy were interviewed at presentation to a tertiary cancer care facility for children in North India. Details from previous prescriptions and referrals, if available, and details of diagnosis (staging and categorization) were recorded. Haematological malignancies included acute leukemia (lymphocytic (ALL), myeloid (AML), undifferentiated (AUL) and non-Hodgkin's lymphoma (NHL)). Risk stratification of disease categories at presentation, from high risk disease and standard risk disease, was completed. Patient delay (symptom - contact interval), health systems delay (contact-diagnosis interval), total delay (symptom- diagnosis interval) and number of contacts were recorded and compared between high risk and standard risk disease groups using descriptive analysis.
Results Of the 79 children (55 boys; 69.6%) with HM, the total number in the high- risk category was 40 (50.6%), and the rest were of the  standard-risk group. The mean age was 5.9 ±3.2 years. The median patient delay of care seeking for children with high - risk HM was 2 (95 % CI; 1.27, 3) days and for children with standartd risk HM was 3 (95% CI;1, 4.22) days (P=0.42). The median system delay of care provided for children with high- risk HM was 27 days and for children with standard risk HM was 40 days (P=0.19). The median symptom to diagnosis interval for children with high risk HM was 29 days and for children with standard risk HM was 45 days (P=0.09). In the standard risk group, 19 (48.7%) had more than 3 contacts whilst in the high-risk category, only 11 (27.7%) had more than 3 contacts (P=0.043). The private sector was similarly approached in both risk groups for medical care. In the study group, the risk category had a significant association with the total delay (spearman correlation coefficient= -0.262, P= 0.02)
Conclusion Sensitizing the private sector practioners and primary care physicians to the possibility of haematological malignancy in children with obvious signs may be the most effective step in a resource poor setting for an early referral.