Jaques van Heerden

Background: Accurate pathological diagnosis is essential for effective childhood cancer management, yet paediatric oncology pathology capacity across Africa remains inadequately characterised. This study aimed to establish a baseline assessment of pathology service capacity, workforce composition, diagnostic infrastructure, quality systems, and training needs across the continent. Methods: A cross‐sectional online survey was conducted among pathologists within the SIOP Africa professional network between September 2025 and April 2026, assessing five domains: respondent characteristics, pathology infrastructure, diagnostic capabilities, quality indicators and fellowship training needs. Quantitative data were analysed descriptively, while free‐text responses underwent thematic content analysis. Results: Eighty‐five pathologists from 19 African countries participated. Most respondents were early‐ to mid‐career anatomical pathologists (81%) working in university or national referral hospitals (75%). Although histopathology was widely available (99%), access to advanced diagnostics was limited, with immunohistochemistry available in 47% of facilities and flow cytometry and molecular diagnostics in only 15%. Routine histopathology turnaround times exceeded 7 days in 76% of centres, and only 48% reported participation in external quality assurance programmes. Interest in further training was high (88%), with paediatric pathology (65%), molecular pathology (52%) and cytopathology (39%) identified as priority areas. Major challenges included limited diagnostic capacity, infrastructure and equipment shortages, workforce gaps, and inadequate specialist training opportunities. Conclusions: This study highlights substantial gaps in paediatric oncology pathology capacity across Africa, spanning from limited access to advanced diagnostics to shortages of subspecialist expertise. The strong demand for fellowship training presents an opportunity for investment in sustainable, context‐specific capacity‐building strategies to strengthen paediatric cancer care across the continent.

Background: In South Africa, the metastatic response rate for stage 4 high-risk neuroblastoma (HR-NB) to induction chemotherapy is lower than that of similar regimens in well-resourced settings. Augmenting current induction chemotherapy regimens with molecular radiotherapy, without increasing toxicity, is an attractive systemic treatment in radioisotope-avid tumors, especially in a resource-limited setting where stem cell transplantation and immunotherapy are unavailable and costly. Clinical trials of [ ¹⁷⁷ Lu]Lutetium DOTATATE ([ ¹⁷⁷ Lu]Lu-DOTATATE) have primarily focused on refractory or relapsed HR-NB, with disappointing results. This study evaluates the feasibility and dose-limiting toxicity grading of adding a single dose of [ ¹⁷⁷ Lu]Lu-DOTATATE to induction chemotherapy in achieving metastatic remission rates. Objective: The aim of the proof-of-concept, open-label study is to evaluate the safety and efficacy of induction [ ¹⁷⁷ Lu]Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) on postinduction response rate in children diagnosed with HR-NB. The primary objectives are to evaluate the dose-limiting toxicity profile of participants treated with induction [ ¹⁷⁷ Lu]Lu-DOTATATE PRRT in conjunction with standard induction chemotherapy; to evaluate the dosimetry in South African patients receiving induction [ ¹⁷⁷ Lu]Lu-DOTATATE PRRT; and to evaluate the feasibility related to resources in patients treated with induction [ ¹⁷⁷ Lu]Lu-DOTATATE PRRT in conjunction with standard induction chemotherapy. The secondary objective is to determine the postinduction metastatic response rate in patients diagnosed with HR-NB after receiving induction [ ¹⁷⁷ Lu]Lu-DOTATATE PRRT in conjunction with standard induction chemotherapy. Methods: The LuDO-SA trial is a phase 1, open-label, multicenter, 2-arm, randomized controlled clinical trial. Children aged 18 months to 18 years are eligible. The experimental arm, consisting of a single dose of [ ¹⁷⁷ Lu]Lu-DOTATATE after cycle 1 of OJEC (vincristine, carboplatin, etoposide, and cyclophosphamide) and OPEC (vincristine, cisplatin, etoposide, and cyclophosphamide) chemotherapy, will be compared to the standard arm of OJEC and OPEC chemotherapy. The postinduction metastatic response rate is based on the International Neuroblastoma Response Criteria (INRC). The statistical analysis will be descriptive. The Fisher exact test will be used to evaluate the significance of end-of-trial outcomes. Results: The trial received institutional ethics approval from 4 South African universities in 2022 and SAHPRA (South African Health Products Regulatory Authority) regulatory approval. The trial, funded by Kinderkankerfonds vzw and the UZA Foundation, commenced recruitment in January 2023. As of July 2026, a total of 15 patients have been enrolled across 4 academic hospital sites. Recruitment is projected to be completed by June 2027, with results expected to be published in December 2027. Conclusions: In this paper, we present the protocol of the LuDO-SA trial. The rationale and design of the trial in a resource-limited setting and its use in first-line regimens are discussed, and the current status of international [ ¹⁷⁷ Lu]Lu-DOTATATE molecular radiotherapy trials is summarized.

PURPOSE: Children with cancer in low- and middle-income countries face high preventable in-hospital mortality, often because of delayed recognition of clinical deterioration. Pediatric Early Warning Systems (PEWS) enable early detection but require frequent clinician assessments that are difficult to sustain in resource-constrained settings. The Family-Assisted Severe Illness Therapy (FASTER) tool trains caregivers to perform simple bedside assessments as an alternative screening approach. We evaluated the concurrent validity, feasibility, and acceptability of caregiver-recorded FASTER scores versus clinician-recorded PEWS scores among pediatric oncology inpatients at the Uganda Cancer Institute. METHODS: In this prospective, concurrent validity study, 50 caregiver-patient pairs were enrolled. After structured training, caregivers performed FASTER assessments every 6 hours over 48 hours while a study nurse independently recorded PEWS scores every 8 hours, yielding 321 concurrent paired observations for analysis. Concurrent validity was assessed using Spearman correlation and kappa agreement statistics. Diagnostic performance for PEWS-defined deterioration (PEWS ≥3) was evaluated using sensitivity, specificity, predictive values, and AUROC. Feasibility and acceptability were assessed through adherence monitoring and structured exit interviews. RESULTS: FASTER scores correlated moderately to strongly with PEWS scores (ρ = 0.65 [95% CI, 0.58 to 0.71]; P < .001), although categorical agreement was poor (unweighted κ = 0.07). For PEWS-defined deterioration, FASTER showed high sensitivity (96.7%) and modest specificity (47.5%); AUROC was 0.89 (95% CI, 0.84 to 0.94), reflecting yellow-threshold discrimination given only two PEWS-red events. The positive predictive value was 29.7%, and the negative predictive value was 98.4%. Caregiver adherence was high (98.3%), and acceptability was strong (100% useful, 78% easy/very easy), although lower education predicted greater difficulty ( P = .014). CONCLUSION: FASTER demonstrated concurrent validity with PEWS and high feasibility and acceptability; its predictive validity and impact on clinical outcomes require further study.

Introduction: Colorectal cancer (CRC) is increasing in Africa, yet reports in children and adolescents are limited. We describe the epidemiology, management, and survival outcomes of CRC in African children. Methods: Retrospective data of children under 19 years diagnosed with CRC between 2000 and 2023 were collected from 14 African countries. Patient and tumor characteristics and treatment data were described and survival outcomes analyzed. GLOBOCAN data were used to evaluate age‐related geographical distribution of CRC. Results: Hundred‐and‐eight patients, 57.4% males, were diagnosed with a mean age of 14.9 (range 5–18) years. The mean symptom‐onset‐to‐diagnosis duration was 90 days (range 2–1200). Most common symptoms were abdominal discomfort (70.6%) and change in bowel habits (57.8%). The commonest primary site was the ascending colon (30.6%) with a mean tumor size of 64.3 mm (range 30–150 mm) and 37% presenting in stage III and 36.1% in stage IV. Most (83.3%) tumors were confirmed on histology, of which 78.7% were adenocarcinoma. Carcinoembryonic antigen was performed in 38.9% of patients. Complete resection was achieved in 55.6% of cases, while 18.5% received radiotherapy. Folinic acid, Fluorouracil, Oxaliplatin (FOLFOX) was the first line chemotherapy in 48.1% of patients. A third of patients were lost to follow‐up while 25.6% experienced disease progression. The 2‐year and 5‐year overall survival rates were 40.0% and 16.9%, respectively. Disease stage ( p = 0.07) and degree of resection ( p = 0.02) predicted outcomes. Conclusion: Pediatric CRC is characterized by delayed diagnosis and advanced stage presentation, contributing to a significantly lower overall survival compared to adults. Focused research and multidisciplinary management are needed to understand pediatric CRC and improve outcomes.

Introduction: In Africa, where pediatric cancer survival rates remain low due to interrelated health system challenges, continent-wide data on the availability, training pathways, and distribution of pediatric oncology pharmacists (POPs) are poorly characterized. This study aimed to assess the presence of pharmacists, the availability of formal POP training across pediatric oncology units (POUs) in Africa, and to map existing continent-based training initiatives. Methods: This study profiled POP workforce capacity and training across Africa using data from 109 POUs in 41 countries listed in the SIOP Global Mapping Programme (GMP). POP training programmes were identified through online searches, professional networks, and direct outreach, with data collected on duration, content, accreditation, and trainee capacity. Data collection occurred from February to March 2025, supported by the formation of the African Pediatric Oncology Pharmacy Group (APOP). Results: APOP was established in January 2025, enrolling 97 pharmacists from 28 countries to strengthen networking, mentorship, research collaboration, and standardized training. Among 109 POUs, 83.5% reported a dedicated pharmacist, though coverage varied regionally: Northern Africa (95%), Southern Africa (88%), West Africa (78%), and East/Central Africa (62%). Only three formal POP training programmes were identified, in Egypt, Morocco, and Ghana, varying in duration, certification status, and annual trainee capacity. Collectively, these programmes train approximately 32 pharmacists per year against a backdrop of growing continental need. Conclusion: Although the majority of POUs have a dedicated pharmacist, formal POP training remains scarce. The substantial gap between the availability of training-qualified personnel and access to structured, accredited programmes underscores the need for investment in POP training infrastructure. Enhancing pharmacy training and fostering professional networks are critical to strengthening paediatric oncology care across Africa.

PURPOSE: The timely diagnosis and referral of children with cancer have been identified as a priority for pediatric oncology. Despite the prominence of timely detection educational interventions, scant data exist on the approach and efficacy of these trainings. METHODS: For this scoping review, PubMed, Web of Science, Scopus, and SciELO were searched to identify studies reporting on educational interventions for the timely detection of pediatric patients with cancer. RESULTS: Our search yielded 5,682 studies, and 29 met the inclusion criteria. These studies captured experiences from 20 countries. Interventions were most frequently conducted in person (12 of 29, 41.4%), with varying formats including workshops (10 of 29, 34.5%), multiday courses (5 of 29, 17.2%), and lectures (4 of 29, 13.7%). Seven studies (24.1%) reported the use of supplementary materials such as job aids, posters, or flyers. Interventions focused on increasing recognition of the signs and symptoms of childhood cancers (25 of 29, 86.2%), whereas some addressed referral practices (11 of 29, 37.9%). Audiences were varied, but included physicians (23 of 29, 79.3%) most often. Most studies (28 of 29, 96.6%) evaluated the impact or outcomes of their educational interventions. Most studies assessing the impact reported the number of participants trained (23 of 29, 79.3%). Knowledge assessment was conducted immediately in 11 studies (37.9%). Additional outcomes included the number of patient referrals (9 of 29, 31.0%), the number of new childhood cancer cases (4 of 29, 13.8%), time to diagnosis (4 of 29, 13.7%), and the stage distribution of cancers at diagnosis (6 of 29, 20.7%). CONCLUSION: Our review highlights the potential of educational interventions to improve provider knowledge and referral practices in childhood cancer diagnosis. Yet, current interventions vary widely in scope, content, and outcome measures. Further research is needed to address methodological limitations and ensure that greater awareness yields meaningful improvements in pediatric cancer outcomes worldwide.

Background: Cystic fibrosis (CF) is an autosomal recessive inherited chronic disorder that predisposes adults to gastrointestinal malignancies. The latter has not been observed in children, perhaps due to the limited documentation of the copresentation of childhood cancer in CF. The following review will provide a comprehensive overview of the relevant literature on this subject. Methodology: The objective of this study was to identify cases in Belgium over a 25‐year period and to review the literature for similar cases. Our secondary objective was to identify areas of attention during oncological management based on the clinical cases and extant literature. Results: Four cases were diagnosed in Belgium and a further 10 cases were identified in the literature. These fourteen cases exhibited a 1:1 male‐to‐female ratio. Four cases were hematological malignancies, and 10 cases were solid tumors, predominantly neuroblastomas and osteosarcomas. No specific age group predominated at the time of diagnosis of the malignancy. As the literature indicated that organs were at risk in all systems, at increased risk for treatment toxicities, and a need for increased nutritional and antimicrobial support. The threshold for intervention with supportive care should be substantially lower than in non‐CF patients. These patients are predisposed to an increased risk for premature morbidity and mortality. Conclusion: Short and long‐term CF‐specific survivorship care plans should be developed based on both disease entities in anticipation of compounded risks for early cardio‐respiratory disease and an increased awareness of secondary cancer screening. Research into the copresentation of these diseases should be promoted.

PURPOSE: Risk/treatment stratification for children with neuroblastoma (NB) relies on clinical, histologic, and genomic factors. However, most children with cancer live in low- and middle-income countries (LMIC), where access to advanced methods for stratification is limited. To address this unmet need, we developed a novel risk/treatment classification, the Adaptive Clinical Neuroblastoma Risk Groups (ACNRG) using clinical prognostic biomarkers. PATIENTS AND METHODS: A survival tree regression analysis of the International Neuroblastoma Risk Group (INRG) Data Commons (N = 14,501, diagnosed 1990-2014) was performed using univariate Cox regression models (age, International Neuroblastoma Staging System, serum lactate dehydrogenase [LDH], and serum ferritin) of event-free survival (EFS), separately for test and validation sets. Within each terminal node of the survival tree, the proportion of patients by initial treatment assignment and outcome achieved on that treatment were used to subjectively assign risk/treatment intensity (low-, intermediate-, and high-risk). For additional validation, the ACNRG was descriptively compared with INRG classification. Guidelines were developed for determining INRGs Staging System (INRGSS) in LMIC, using the minimum essential versus optimal imaging/biopsy procedures. RESULTS: Twelve statistically, clinically significant unique pretreatment risk groups of INRGSS/age/LDH/ferritin were identified (5-year EFS): low—L1/any/any/any (92% ± 0.5%); intermediate—L2/<18 months/<1,400/any (88% ± 1%), MS/any/<1,400/any (86% ± 1.5%), M/<12 months/<1,400/any (76% ± 2.3%); intermediate/high—L2/<18 months/≥1,400/any (73% ± 4.7%), L2/≥18 months/<1,400/<30 (68% ± 3.4%), L2/≥18 months/<1,400/≥30 (59% ± 3.7%), MS/any/≥1,400/any (52% ± 6.3%); high—L2/≥18 months/≥1,400/any (46% ± 4.7%), M/12-18 months/<1,400/any (64% ± 4.1%), M/<18 months/≥1,400/any (60% ± 1.6%), M/≥18 months/any/any (28% ± 0.8%). The concordance and discordance rates of ACNRG versus INRG were 86.6% and 13.4%, respectively (n = 8,152 nonmissing-data intersection). CONCLUSION: The ACNRG classification, using easily obtained clinical markers, is highly prognostic. The ACNRG could transform risk and treatment stratification, improve accuracy of treatment intensity decisions, and potentially improve outcome, for the large number of children with NB in LMIC. Prospective validation of the ACNRG classification is planned in a pilot trial.

Introduction: Pediatric low-grade glioma (LGG) is a World Health Organization (WHO) Global Initiative for Childhood Cancer (GICC) index tumor constituting up to a third of pediatric central nervous system (CNS) tumors. The baseline characteristics, survival, and management resources for pediatric LGG in Africa are unknown. We aimed to evaluate the pediatric neuro-oncology multidisciplinary team resources, epidemiology, and survival outcomes of pediatric LGG in Africa to document baseline information prior to GICC implementation.Methods: The study consisted of two parts: a survey completed by African pediatric oncology units (POU) to evaluate the local resources and a retrospective evaluation of data to determine the 5-year overall survival (OS) for patients under 18 years diagnosed with LGG between 2008 and 2018. Data were described in frequencies and percentages. Survival was expressed with Kaplan–Meier curves.Results: Five-hundred and eighty-eight patients were included from fifteen POUs in six countries: South Africa (45.9%), Egypt (30.8%), Morocco (12.6%), Mali (4.4%), Tunisia (3.6%) and Uganda (2.7%). The median age was 4.4 years (interquartile range 2.4–7.3 years). The most common primary tumor site was the brainstem (n = 125, 21.3%), the most common histology was pilocytic astrocytoma (n = 270, 47.5%), the majority of tumors (n = 292, 93%) were localized, and 40 (6.8%) patients had neurofibromatosis. Complete resection was obtained in 99 (16.8%) cases, incomplete resection in 179 (30.4%), and no surgery or biopsy only was performed in 310 (52.7%) cases. One hundred and forty-seven (25.3%) of the 580 patients with a documented radiotherapy status, were irradiated, and 320 (54.4%) received chemotherapy. Only 259 (15.3%) patients received chemotherapy of which the most common chemotherapy regimen was vincristine-carboplatin (n = 220, 84.9%). The 5-year OS was 90.5% ± 1.6%. The 5-year OS in Tunisia was 95.1% ± 1.1%, 92.4% ± 2.1% in Egypt, 89.0% ± 3.2% in South Africa, 70.7% ± 6.7% in Morocco and 66.7% ± 15.7% in Uganda (p < 0.001). Four of the 41 (9.8%) responding countries reported having pediatric neuro-oncology subspecialists, and four (9.8%) had national pediatric LGG protocols. In Africa there is one radiotherapy center per 2,235,125 children and one neurosurgeon per 304,685 children, with ~70% of these resources accessible in four countries.Discussion: Due to several resource challenges and developing treatment centers, only fifteen pediatric oncology units from six countries participated. We documented a baseline 5-year OS of 94.9% for LGG in African children. To obtain an accurate estimation of pediatric LGG survival in Africa, increasing participation from a wider range of countries, especially poorly resourced settings, is necessary.