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Improve Quality Childhood Cancer Care in Uganda

by The International Network for Cancer Treatment and Research (INCTR)
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Improve Quality Childhood Cancer Care in Uganda
Gillian Post Chemotherapy
Gillian Post Chemotherapy

Gillian was five years old when she first came to St. Mary’s Hospital Lacor in Gulu, Uganda. Her father, who accompanied her, reported that she had a three-week history of progressive abdominal swelling associated with pain. He also stated that she had a reduced appetite and when she did eat, she felt full and could not complete her meals.  When we examined Gillian, she had a grossly distended abdomen and an obvious mass in the right lumbar region.  The mass was not tender and had a smooth surface.   She did not have pallor, jaundice, or swelling in her lower limbs.  Despite her decreased appetite, her nutritional status was good.  

Gillian underwent a series of examinations including routine blood work, a chest x-ray, and a scan of her abdomen. The abdominal scan revealed that she had a large mass in her right kidney and multiple masses in her liver. A tru-cut needle biopsy of the mass was performed. The results of the biopsy confirmed that Gillian had Wilms tumor, a type of kidney cancer that occurs in young children. Wilms tumor is the second most common childhood cancer that we see at St. Mary's. 

When we examined the tumor cells further, it was determined she had an unfavorable type of Wilms tumor. Because Gillian also had disease that had spread to her liver, her prognosis was considered poor.  After counselling about her diagnosis and prognosis, her parents gave their consent to start her on our treatment regimen for Wilms tumor. She began with several cycles of chemotherapy and then underwent the surgical removal of her right kidney. Upon recovery from her surgery, she was re-started on chemotherapy. After her third cycle of post-operative therapy, she was discharged to her home in a rural village in the Amuru district which is a two hour journey – under the best of circumstances – from St. Mary’s Hospital to recover from this cycle of chemotherapy.

Unfortunately, while she was home, the Ugandan government instituted a ban on the use of public transportation because of the global pandemic caused by the novel coronavirus, Covid-19.  This meant that Gillian did not return to resume her much needed chemotherapy.  After many weeks had passed, a local organization found Gillian at home in her village and brought her back to our hospital.  

Once she was back at St. Mary's, we undertook studies to ensure that her cancer had not returned.  Thankfully, she had no evidence of disease. Gillian went on to complete all planned chemotherapy. Two months after treatment completion, Gillian and her father returned to the hospital and we are pleased to report that she remains free of disease and is doing very well.  

We would like to thank the people who support this project. Without your generous donations, children like Gillian would not have access to free treatment and therefore, would have no chance of cure.  Thank you again for your support!

  

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Family Assessment at St Mary's During Lockdown
Family Assessment at St Mary's During Lockdown

The first case of the novel coronavirus, COVID-19 was reported in Uganda in late March. Around this same time, the Ugandan government placed a ban on the use of public transportation, in addition to implementing other types of restrictions, to prevent the spread of the virus. These have markedly reduced access to care for children with cancer.  

While the use of government ambulances was permitted and private vehicles could be hired for transportation, the costs were high ($20 to $50). Boda-bodas - or motorcycles - could also be hired for travel within the wider Gulu district, and although the costs were less ($15 to $30), they were still too high.  This is because most families live on less than three dollars a day in the best of times and parents simply could not afford to bring their children to St Mary’s at these prices.  

With this in mind, we developed an emergency response plan that was put into place in April to cover the transportation costs for parents of children with cancer. Children who had been discharged to home in-between treatment cycles were brought back to St Mary’s and when they completed their next course of treatment, they were taken home. We also brought children who had completed their planned treatment back to the hospital for routine follow-up appointments. Children who had been waiting for several weeks at the hospital to be discharged after all planned treatment was completed were taken home. Financial support mechanisms for children living outside of the Gulu District were also implemented.  Since this plan was put into place in April, we have been able to support 45 children with transportation to and from the hospital.  

St Mary’s typically sees 10 to 15 newly diagnosed children with cancer each month. But, from late March through the end of May, only three such patients were admitted to the hospital. We hope to bring more children with suspected cancer to our hospital for care. Even with our best efforts to improve transportation support mechanisms, we know that many other children under our care have abandoned treatment altogether at this time.

Your donations have made it possible for us to assist families with transportation costs. With your continued support, particularly during this period, you can help us to ensure that as many children with cancer as possible receive the treatment they need. Thank you very much for your donations!    

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Raphaella and her Mother
Raphaella and her Mother

Raphaella came to our hospital, St Mary’s Hospital Lacor in Gulu, in November of 2018 when her father decided to bring her to us because she was not improving with treatment given to her by their local health center. The doctors at the health center thought that Raphaella had a hyperactive malaria syndrome and treated her with anti-malarial drugs for many months.

Her father explained that Raphaella had a 7 month history of progressive abdominal distention that was associated with pain, intermittent fevers, and weight loss. Two weeks prior to admission, she developed chest pain associated with a cough. Further complicating her problems was that Raphaella had known epilepsy which was not properly controlled – her parents could not afford the costs of transportation to obtain the necessary drugs to treat this condition.

Upon admission, Raphaella was very sick. She had a grossly distended abdomen and was severely malnourished. We immediately began tests and found that she had an enlarged left kidney and that disease had spread to her spleen, liver, and lungs. A biopsy was performed which confirmed our suspected diagnosis of Wilms tumor – a type of childhood cancer that arises in the kidney. In our setting, Wilms is treated with pre-operative chemotherapy before we surgically remove the affected kidney (nephrectomy). A nephrectomy, which is a necessary part of treatment for Wilms tumor, is followed by post-operative chemotherapy for a period of time. We were heartened that after 8 weeks of pre-operative chemotherapy, the lesions in her liver, spleen and lungs had completely resolved. She, then, underwent a successful removal of her left kidney.  Unfortunately, Raphaella developed several post-operative complications and required two more surgeries, including a colostomy.  This meant that we had to delay her post-operative chemotherapy for nearly 8 weeks to allow her to recover from these extra surgeries.

Once Raphaella started post-op chemotherapy, she suffered all of the challenges associated with the known side effects of the drugs used. At one point, she developed such a severe infection due to her low levels of infection fighting white blood cells that she nearly lost her life. But, Raphaella was such a fighter and she survived. She stayed at the hospital’s Family Home during treatment to ensure that we could deliver chemotherapy on time and monitor her closely so that we could intervene promptly when treatment-related complications arose. Raphaella completed all chemotherapy in October 2019. We are pleased to report that she is free of cancer and that we were able to close her colostomy. With appropriate anti-seizure medications, her epilepsy is now well-controlled. She returns to St Mary’s for regular follow-up visits.

Raphaella’s story reminds me how necessary it is to improve and intensify public and health workers’ awareness about the signs and symptoms of childhood cancer at the community level so that referrals of children with suspected cancers can be made as quickly as possible.

It also taught me that children with cancer - no matter how extensive their disease is at presentation – deserve the opportunity to have the correct treatment and to be given the chance to live. Therefore, I would like to thank everyone who donates to this project because your support makes it possible for St Mary’s to accurately diagnose and treat children like Raphaella.  

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Children Enjoying Activities at School
Children Enjoying Activities at School

In early 2018, Joyce was appointed as the teacher for children with cancer who undergo treatment at St Mary’s Hospital Lacor in Gulu, Uganda. She opened the Rainbow Family Home School within the premises of the Family Home that is located on the hospital’s grounds. As INCTR previously reported, the main goal of the educational program for the children is to enable them to cope with life while undergoing cancer treatment.  The main elements of the curriculum include reading, writing, mathematics, social studies, health and basic English. Recreational and social activities are also major components of the program.

When Joyce began, it was not easy because the children spoke in many local languages and some, although of school-age, had never been in a formal classroom before. One of her earlier decisions was to teach the children in one common language – English. She found that children – of all ages – were eager to learn and many who had missed going to school were more than happy to have the opportunity to keep up with school while away from home.  This was also important to their parents who did not want their children to fall behind other children of the same age.    

Children with some types of cancer, such as Burkitt lymphoma, often present with disfiguring tumors in the facial region. While this cancer rapidly responds to treatment, it can take some time for abnormalities to completely resolve. At the Rainbow Family Home School, the children find that they fit in. Their shyness about their appearances quickly disappear because their fellow students and Joyce warmly welcome them.

The school provides a friendly environment for children to learn and to have emotional support they need - from Joyce and from other children suffering from cancer. Children often need to stay at the Family Home for prolonged periods of time during treatment. The reasons vary from patient to patient, but the most common reason is the long distance and/or the unreliability of transportation (including costs) from home to the hospital that inevitably lead to unnecessary disruptions in or abandonment of treatment when parents wish to return home in-between their child’s treatment cycles to care for their other children and to resume work to sustain their families.  

It should be noted that when the school was opened, St Mary’s management team and staff considered it an “experiment” and were sceptical about it being successful. Their opinions rapidly changed. The Institutional Director recently wrote to say; “The teacher is doing a great job. I see faces of happiness and without INCTR, I would not have envisaged how useful this venture would be”.

Thanks to everyone who has donated so generously to this project. Your donations mean that children with cancer treated at St Mary's have the opportunity to keep up with school and to have recreational and social activities that improve the quality of their lives while undergoing treatment.  

 

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Edmond with his Dad and a Volunteer
Edmond with his Dad and a Volunteer

Edmond was 6 years old when he came to St Mary’s Hospital Lacor in Gulu, Uganda in late 2017. His father had noted a swelling in Edmond’s left cheek that had begun about a month prior to his admission to St Mary’s. The swelling was painful and caused the loss of two teeth. Although he was initially managed at home with pain medication, there was only minimal improvement and he soon developed a swelling in his right cheek. He also had difficulty eating.

Edmond underwent a full examination that included a biopsy of the mass in his jaw. Because of the jaw swellings, which are classical features of Burkitt lymphoma, he was started on treatment for this cancer. After the first two cycles of therapy, he had no improvement. At this point in time, a complete and final pathology report came back which included the results of special tests performed on the pre-treatment biopsy sample. The final diagnosis was rhabdomyosarcoma. Rhabdomyosarcoma can have similar clinical features to Burkitt lymphoma in younger children. Edmond was switched to the appropriate therapy for rhabdomyosarcoma. He completed treatment in early 2019 and is currently free of cancer.  He returns for regular for post-treatment check-ups at the hospital.

Because Burkitt lymphoma accounts for nearly 50% of childhood cancers in equatorial Africa, many hospitals in this region of Africa start treatment based upon what is often called a “clinical diagnosis”.  Sometimes hospitals do not have pathology departments or the capacity to perform biopsies.  Even if a hospital has the capacity to perform a biopsy on a child with suspected cancer, they may not have a staff pathologist.  In these situations, doctors need to send the samples to another hospital in order to obtain the diagnosis.  This process can be lengthy.  It is well known that Burkitt lymphoma is a rapidly growing cancer and is fatal if not treated promptly.  Therefore, doctors make the decision to treat a child with therapy for Burkitt lymphoma, in the absence of a confirmed diagnosis, in order to try to save the child’s life.  Even if a hospital has a pathologist on staff, the pathologist may only be able to examine the appearance of the cells taken from the biopsy of the tumor and may not be able to perform special tests that are often required to make a more precise diagnosis.  Furthermore, the resources to perform these tests are often cost-prohibitive for many hospitals.  Pathologists are often in short supply in many regions within sub-Saharan Africa.  When a pathologist is on educational or personal leave, gaps in services occur which result in delays in diagnoses for children with suspected cancer.

Unfortunately, clinical diagnoses can have consequences for children and their families. The children receive, often at their families’ expense, incorrect therapy and suffer what are thought to be relapses of a cancer that they never had.  In Edmond’s case, he was very lucky to have dedicated doctors who recognized that he was not improving on Burkitt lymphoma therapy.  The doctors were fortunate to have a staff pathologist capable of making an accurate diagnosis based upon specialized tests so that Edmond’s treatment could be changed. 

We wish to thank everyone who has generously supported this project.  Your donations ensure that St Mary’s Hospital receives the necessary resources for improving the accuracy of diagnoses made in children suspected of having cancer and that the children receive support for the costs of treatment.  Thank you!

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Project Leader:
Melissa Adde
Brussels, Belgium
$16,337 raised of $75,000 goal
 
122 donations
$58,663 to go
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