ABSTRACT

This report describes the status of childhood cancer control initiatives in Latin America and the Caribbean (LAC). Progress between 2017 and 2023 is measured using the outcome indicators from the Pan American Health Organization (PAHO) childhood cancer logic model aligned with the World Health Organization Global Initiative for Childhood Cancer (GICC). This report also describes the advances, barriers, and facilitators for the implementation of the GICC at the Regional level. Methods used in this report encompassed a comprehensive approach, incorporating a literature review, interviews, surveys, and a Delphi study developed by the technical team of the PAHO Non-Communicable Diseases and Mental Health Department and by the GICC LAC working group. Since 2017, there has been a substantial increase in the number of countries that have included childhood cancer in their national regulations. Currently, 21 LAC countries are involved in the GICC implementation, activities, and dialogues. However, the objectives for 2030 will only be achieved if Member States overcome the barriers to accelerating the pace of initiative implementation. There is an urgent need to increase the efforts in childhood cancer control in LAC, especially regarding the prioritization of timely detection, essential diagnostics, access to cancer treatment, palliative care, and close follow-up of children and adolescents with cancer.

Keywords
Child health; neoplasms, prevention & control; Latin America; Caribbean region

RESUMEN

En este artículo se describe la situación de las iniciativas para el control del cáncer infantil en América Latina y el Caribe. Para medir los progresos entre el 2017 y el 2023, se utilizan los indicadores de resultados del modelo lógico del cáncer infantil de la Organización Panamericana de la Salud (OPS) que es coherente con la Iniciativa Mundial contra el Cáncer Infantil de la Organización Mundial de la Salud. También se describen los avances, los obstáculos y los elementos que han facilitado la aplicación de esa iniciativa en la Región Los métodos utilizados en este trabajo incluyeron un enfoque integral que incorporó una revisión bibliográfica, entrevistas, encuestas y un estudio de tipo Delfos llevado a cabo por el equipo técnico del Departamento de Enfermedades No Transmisibles y Salud Mental de la OPS y por el grupo de trabajo de América Latina y el Caribe de la Iniciativa Mundial contra el Cáncer Infantil de la Organización Mundial de la Salud.

Desde el 2017 ha habido un incremento considerable en el número de países que incorporan el cáncer infantil en sus regulaciones nacionales. En la actualidad, 21 países de América Latina y el Caribe participan en la puesta en práctica, las actividades y las deliberaciones de la Iniciativa Mundial contra el Cáncer Infantil de la Organización Mundial de la Salud. No obstante, los objetivos para el 2030 solo podrán alcanzarse si los Estados Miembros son capaces de superar los obstáculos que dificultan la aceleración del ritmo de aplicación de esta iniciativa. Existe una necesidad urgente de aumentar las actividades dirigidas al control del cáncer infantil en América Latina y el Caribe, en especial en lo que respecta a priorizar la detección temprana, los medios de diagnóstico esenciales, el acceso a los tratamientos oncológicos, los cuidados paliativos y el seguimiento estricto de la población infantil y adolescente con cáncer.

Palabras clave
Salud infantil; neoplasias, prevención & control; América Latina; Región del Caribe

RESUMO

Este relatório descreve a situação das iniciativas de controle do câncer infantil na Região da América Latina e do Caribe (ALC). O progresso alcançado entre 2017 e 2023 foi medido usando os indicadores de resultados intermediários do modelo lógico de câncer infantil da Organização Pan-Americana da Saúde (OPAS), em linha com a Iniciativa Global para o Câncer Infantil (GICC) da Organização Mundial da Saúde. O relatório também descreve os avanços, as barreiras e os facilitadores para a implementação da iniciativa em nível regional. Os métodos utilizados neste relatório aplicaram uma abordagem abrangente que incluiu revisão da literatura, entrevistas, levantamentos e um estudo Delphi desenvolvido pela equipe técnica do Departamento de Doenças Não Transmissíveis e Saúde Mental da OPAS e pelo grupo de trabalho da GICC para a ALC.

Desde 2017, houve um aumento significativo no número de países que passaram a incluir o câncer infantil em regulamentações nacionais. Atualmente, 21 países da América Latina e do Caribe estão envolvidos na implementação da GICC, bem como em atividades e diálogos relacionados. No entanto, os objetivos para 2030 só serão alcançados se os Estados Membros superarem as barreiras ao aceleramento do ritmo de implementação da iniciativa. Existe uma necessidade urgente de intensificar os esforços de controle do câncer infantil na ALC, especialmente no tocante à priorização da detecção em tempo hábil, diagnósticos essenciais, acesso a tratamentos oncológicos, cuidados paliativos e acompanhamento cuidadoso de crianças e adolescentes com câncer.

Palavras-chave
Saúde da criança; neoplasias, prevenção & controle; América Latina; Região do Caribe

Childhood cancer is a public health issue that affects at least 29 000 children and adolescents (0–19 years old) in Latin America and the Caribbean (LAC) every year (¹1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209-249. doi:10.3322/caac.21660.
https://doi.org/10.3322/caac.21660... ). Of these, nearly 10 000 will die from the disease, representing the leading cause of disease-related death in this age group (²2. Pan American Health Organization. Childhood and adolescence cancer. [Accessed 28 February 2023]. Available from: https://www.paho.org/en/topics/childhood-and-adolescence-cancer.
https://www.paho.org/en/topics/childhood... ). Lack of accessibility to appropriate and affordable treatments, health care infrastructure, early detection programs, diagnostic technology, and essential medicines, along with coexisting malnutrition and communicable diseases, contribute to large disparities in childhood cancer survival among LAC countries (³3. Rodriguez-Galindo C, Friedrich P, Alcasabas P, Antillon F, Banavali S, Castillo L, et al. Toward the cure of all children with cancer through collaborative efforts: pediatric oncology as a global challenge. J Clin Oncol. 2015;33(27):3065-73. doi:10.1200/JCO.2014.60.6376.
https://doi.org/10.1200/JCO.2014.60.6376...

4. Ward ZJ, Yeh JM, Bhakta N, Frazier AL, Girardi F, et al. Global childhood cancer survival estimates and priority-setting: a simulation-based analysis. Lancet Oncol. 2019;20(7):972-983. doi:10.1016/S1470-2045(19)30273-6.
https://doi.org/10.1016/S1470-2045(19)30... -⁵5. Atun R, Bhakta N, Denburg A, Frazier AL, Friedrich P, Gupta S, et al. Sustainable care for children with cancer: a Lancet Oncology Commission. Lancet Oncol. 2020;21(4):e185-e224. doi:10.1016/S1470-2045(20)30022-X.
https://doi.org/10.1016/S1470-2045(20)30... ). Childhood cancer imposes a high burden of disease, accounting for a major loss of disability-adjusted life-years (DALYs) and surpassing other pediatric diseases and adult cancers. DALYs represent the combined effects of premature death and disability due to a specific condition. In the case of childhood cancer, DALYs capture the years of healthy life lost due to both mortality and the long-term effects of the disease, including physical and psychosocial disabilities (⁶6. GBD 2017 Childhood Cancer Collaborators. The global burden of childhood and adolescent cancer in 2017: an analysis of the Global Burden of Disease Study 2017. Lancet Oncol. 2019;20(9):1211-1225. doi:10.1016/S1470-2045(19)30339-0. Erratum in: Lancet Oncol. 2021;22(8):e347.
https://doi.org/10.1016/S1470-2045(19)30... ).

Aiming to reduce the inequalities in childhood cancer outcomes in low- and middle-income countries (LMIC), the World Health Organization (WHO) and St. Jude Children’s Research Hospital (St. Jude) launched the Global Initiative for Childhood Cancer (GICC) in September 2018. The CureAll technical package guides multi-stakeholder action to improve care and outcomes for all children and adolescents with cancer in LAC by strengthening health systems with four pillars (CURE: Centers and networks of excellence, Universal health coverage, Regimens for diagnosis and treatment of childhood cancer, and Evaluation and monitoring) and three enablers (ALL: Advocacy, Leveraged financing, and Linked governance) (⁷7. Pan American Health Organization. Implementación de la iniciativa mundial de la OMS contra el cáncer infantil en América Latina y el Caribe. [Accessed 28 February 2023]. Available from: https://iris.paho.org/handle/10665.2/53921
https://iris.paho.org/handle/10665.2/539... ).

The GICC aims to reach at least a 60% global survival rate for children with cancer by 2030, thereby saving an additional 1 million lives. This new target represents a doubling of the global cure rate for children with cancer (⁸8. World Health Organization. CureAll framework: WHO Global Initiative for Childhood Cancer. Increasing access, advancing quality, saving lives. Geneva: WHO; 2021.). After the launch of the GICC in the Region of the Americas in June 2019, Peru was selected as the first focus country to start the process of implementing the CureAll framework (⁹9. Vasquez L, Maradiegue E, Rojas N, Montoya J, Zapata A, Ugaz C, et al. Catalyzing childhood cancer care in Peru after one year of the Global Initiative for Childhood Cancer. JCO Glob Oncol. 2021;7:187-189. doi:10.1200/GO.20.00601.
https://doi.org/10.1200/GO.20.00601... ). Several activities were initiated by the Ministry of Health of Peru in collaboration with the Pan American Health Organization (PAHO), St. Jude, and other stakeholders based on three strategic objectives: (i) childhood cancer inclusion in national regulations; (ii) national implementation of the CureAll core projects; and (iii) development of regional projects.

The enormous health, economic, and psychosocial effects of premature mortality and loss of productive life-years associated with cancer in childhood highlight the critical importance of developing, implementing, and monitoring pediatric cancer policies, programs, and interventions in LAC. This study describes the current state of progress in the implementation of the GICC in LAC countries, as well as the barriers and facilitators for its proper development at the regional and national levels.

METHODS

This report focused on the progress related to childhood cancer control among patients from 0 to 19 years of age in 32 countries in LAC: Argentina, Antigua and Barbuda, Bahamas, Barbados, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.

Measurement of advances in GICC implementation

To measure progress, in LAC we compared baseline data from 2017 (before the GICC launch) to the current status (2023) along with the three strategic objectives of the CureAll implementation proposed in the PAHO Regional childhood cancer logic model (Figure 1). To understand the progress, this study performed a comprehensive analysis of the barriers and facilitators for the implementation of the CureAll Americas strategy in LAC countries. Data sources included reports from national regulations and official communications collected by the technical team of the PAHO Noncommunicable Diseases and Mental Health Department and by the GICC LAC working group formed by focal points from the Ministries of Health, pediatric oncologists, civil society, and other stakeholders. Additionally, the methodology for data collection included reviewing scientific and technical literature, surveys, and interviews with subject matter experts, as well as data from health information systems and cancer registries. The content and status of national regulations (including national cancer control plans, national cancer strategies, and national childhood cancer laws and policies), national core CureAll projects, and regional projects were reviewed by at least three childhood cancer experts from PAHO and St. Jude (L.V., S.F.A., and P.L.). A country in full implementation was defined as having at least four complete or active projects and interventions, aligned with the CureAll framework.

Analysis of barriers and facilitators for GICC implementation in LAC

Information on the barriers and facilitators of the CureAll implementation in LAC was collected using a modified e-Delphi technique in two rounds. Semistructured electronic questionnaires were sent to the Regional working group in December 2022 through February 2023 and were conducted in both Spanish and English to ensure inclusivity and active engagement from all members. The questionnaire was divided into three domains (characteristics of the national context, technical assistance, and involved organizations and stakeholders). The process of achieving consensus was carried out through regular GICC LAC working group meetings, which fostered open discussions, knowledge exchange, and collaboration among the participants.

In all, 113 members of the GICC LAC working group were approached to participate. Respondents were asked to rank each item using a Likert scale consisting of five levels, where 5 was very important; 4, important; 3, neutral; 2, not very important; and 1, not important at all. To determine the overall importance of each item, we used two key indicators: the highest mean score and the lowest standard deviation. The highest mean score indicated the items that received consistently higher rankings, reflecting their greater overall importance as perceived by the respondents. Additionally, considering the lowest standard deviation ensured that items with minimal variability in rankings were also recognized as important, indicating a level of consensus among the respondents. The internal consistency of barriers and facilitators’ rating was assessed by Cronbach’s coefficient α (≥0.7 was acceptable). Data analysis was performed using STATA, release 17.0 (StataCorp) and Excel 365 (Microsoft).

Institutional Review Board approval and informed consent were not required for this report because it involved a comprehensive approach of data collection that solely utilized publicly available information from existing literature and a Delphi study conducted by the technical team of the PAHO Noncommunicable Diseases and Mental Health Department and the GICC LAC working group. No individual-level data or sensitive information were involved in the study, ensuring that the privacy and anonymity of subjects were not compromised.

RESULTS AND DISCUSSION

Evaluation results

Strategic outcome 1: Childhood cancer inclusion in national regulations

The target for the first strategic outcome is that by the end of 2030, at least 25 PAHO Member States will have included childhood cancer in their national regulations (i.e., national cancer control plans, national cancer strategies, or national childhood cancer laws and policies). As of July 2023, a total of 13 countries (covering at least 23 180 new cases of childhood cancer each year) had reached this goal, with 10 countries having developed a national regulation policy since 2017 (covering at least 4 102 new cases of childhood cancer each year) (Table 1).

Strategic outcome 2: Implementation of CureAll core projects

The target for the second strategic outcome is that by the end of 2030, at least 25 PAHO Member States will have implemented strategies to strengthen the response capacity in childhood cancer, aligned with the CureAll Americas framework. As of July 2023, a total of 4 countries (covering at least 2376 new cases of childhood cancer each year) had reached this goal, with 18 countries signing a formal consent letter for participation from their Ministries of Health (covering at least 27 981 new cases of childhood cancer each year; Table 1 and Figure 2).

Strategic outcome 3: Development of regional projects

The target for the third strategic outcome is that by the end of 2030, at least 21 PAHO regional projects and documents targeting childhood cancer morbimortality causes will be available in three languages (Spanish, English, and Portuguese). As of July 2023, there were 13 projects and documents (in Spanish) that had been developed (Table 1). Details about the stepwise process of development, validation, and dissemination of these resources will be presented as a separate report.

Achievements in the LAC countries

Currently, several LAC countries have already reached the 2030 WHO target to have at least a 60% national survival rate among children and adolescents with cancer (⁴4. Ward ZJ, Yeh JM, Bhakta N, Frazier AL, Girardi F, et al. Global childhood cancer survival estimates and priority-setting: a simulation-based analysis. Lancet Oncol. 2019;20(7):972-983. doi:10.1016/S1470-2045(19)30273-6.
https://doi.org/10.1016/S1470-2045(19)30... , ¹⁰10. Ministry of Health of Argentina. Registro Oncopediátrico Hospitalario Argentino. [Accessed 28 February 2023]. Available from: https://www.argentina.gob.ar/salud/instituto-nacional-del-cancer/institucional/roha
https://www.argentina.gob.ar/salud/insti... ). Before the GICC, comprehensive national childhood cancer programs and strategies that included essential diagnostic and treatment services, universal health coverage, social protection, and research innovation had enabled improved outcomes in Argentina (¹⁰10. Ministry of Health of Argentina. Registro Oncopediátrico Hospitalario Argentino. [Accessed 28 February 2023]. Available from: https://www.argentina.gob.ar/salud/instituto-nacional-del-cancer/institucional/roha
https://www.argentina.gob.ar/salud/insti... ), Brazil (¹¹11. Union for International Cancer Control. Improving the chances of cure for childhood cancer in Brazil. [Accessed 27 July 2023]. Available from: https://www.uicc.org/blog/improving-chances-cure-childhood-cancer-brazil
https://www.uicc.org/blog/improving-chan... ), Chile (¹²12. Ministry of Health of Chile. Registro Nacional del Cáncer Infantil. [Accessed 28 February 2023]. Available from: http://epi.minsal.cl/registro-nacional-del-cancer-infantil
http://epi.minsal.cl/registro-nacional-d... ), and Uruguay (¹³13. Morosini F, Silveira A, Arias V, Castillo L. Incidência, mortalidade e sobrevida por câncer infantil no Uruguai, 2011-2015. Revista Brasileira De Cancerologia. 2023; 69(1):163054. doi:10.32635/2176-9745.RBC.2023v69n1.3054
https://doi.org/10.32635/2176-9745.RBC.2... ). Important advances in the promotion of “twinning” partnerships, in which hospitals in low- and middle-income countries form partnerships with hospitals in high-income countries, have proven to be immensely successful and effective in advancing pediatric oncology care in several other LMIC countries in the Region (¹⁴14. Ribeiro RC, Antillon F, Pedrosa F, Pui CH. Global pediatric oncology: lessons from partnerships between high-income countries and low- to mid-income countries. J Clin Oncol. 20161;34(1):53-61. doi:10.1200/JCO.2015.61.9148. PMID: 26578620.
https://doi.org/10.1200/JCO.2015.61.9148... ). The development of collaborative groups, such as the Asociación de Hemato-Oncología Pediátrica Centroamericana (¹⁵15. Barr RD, Antillón Klussmann F, Baez F, Bonilla M, Moreno B, Navarrete M, et al. Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA): a model for sustainable development in pediatric oncology. Pediatr Blood Cancer. 2014;61(2):345-54. doi:10.1002/pbc.24802.
https://doi.org/10.1002/pbc.24802... , ¹⁶16. Navarrete M, Rossi E, Brivio E, Carrillo JM, Bonilla M, Vasquez R, et al. Treatment of childhood acute lymphoblastic leukemia in central America: a lower-middle income countries experience. Pediatr Blood Cancer. 2014;61(5):803-9. doi:10.1002/pbc.24911.
https://doi.org/10.1002/pbc.24911... ), Grupo América Latina de Oncología Pediátrica (¹⁷17. Pérez V, Sampor C, Rey G, Parareda-Salles A, Kopp K, Dabezies AP, et al. Treatment of nonmetastatic unilateral retinoblastoma in children. JAMA Ophthalmol. 2018;136(7):747-752. doi:10.1001/jamaophthalmol.2018.1501.
https://doi.org/10.1001/jamaophthalmol.2... ), Consorcio Latinoamericano de Enfermedades Hemato-Oncológicas Pediátricas (¹⁸18. Freigeiro D, Arancibia A, Dibar E, Contreras A, Garcia J, Castellanos M. Is it possible to work together in Latin America? Creation of a Latin American Consortium (CLEHOP). Proceedings of the 2nd International Symposium on Childhood, Adolescent and Young Adult Hodgkin Lymphoma Langenbeck-Virchow-Haus, Berlin, Germany, 7-10 May 2014.), Mexico in Alliance with St. Jude (¹⁹19. Romo H, Gonzalez-Montalvo P, Arce D, Aguilar-Escobar D, Mercado N, Echeandia N, et al. Evaluation of early treatment response utilizing the MAS-ALL18 Adapted Management Guideline in Four “Mexico in Alliance with St. Jude” (MAS) Member Hospitals. Blood. 2021;138(1):1210. doi:10.1182/blood-2021-154325.
https://doi.org/10.1182/blood-2021-15432... ,²⁰20. Gonzalez ML, Aristizabal P, Loera-Reyna A, Torres D, Ornelas-Sánchez M, Nuño-Vázquez L, et al. The golden hour: sustainability and clinical outcomes of adequate time to antibiotic administration in children with cancer and febrile neutropenia in northwestern Mexico. JCO Glob Oncol. 2021; 7:659-670. doi:10.1200/GO.20.00578.
https://doi.org/10.1200/GO.20.00578... ), Aliança Amarte in Brazil (²¹21. Aliança Amarte. Ha promove encontro internacional com 25 centros da ‘Aliança Amarte’, incluindo profissionais do Hospital St. Jude de Memphis. [Accessed 28 February 2023]. Available from: https://hospitaldeamor.com.br/site/tag/alianca-amarte/
https://hospitaldeamor.com.br/site/tag/a... ), and several others have enabled pediatric cancer centers to work together, share knowledge and resources, and conduct clinical trials to improve outcomes for childhood cancer patients.

Collaborative efforts through multiple partnerships and regional dialogues were established in 2016 and have involved representatives from national governments in LAC, PAHO, St. Jude, Canada’s Hospital for Sick Children, Union for International Cancer Control, local universities, and academic societies. These efforts were pivotal in increasing liaisons between various stakeholders in the childhood cancer field (²²22. Denburg A, Cuadrado C, Alexis C, Klussmann FA, Zamora JCB, Bodkyn C, et al. Improving childhood cancer care in Latin America and the Caribbean: a PAHO Childhood Cancer Working Group position statement. Lancet Oncol. 2017 ;18(6):709-711. doi:10.1016/S1470-2045(17)30325-X.
https://doi.org/10.1016/S1470-2045(17)30... , ²³23. Pan American Health Organization. Meeting of the Pediatric Cancer Working Group. Washington, DC, 2-3 February 2017. [Accessed 28 February 2023]. Available from: https://iris.paho.org/handle/10665.2/34024
https://iris.paho.org/handle/10665.2/340... ). Finally, in the Caribbean subregion, the SickKids Caribbean Initiative has improved the local capacity to diagnose, treat, and manage pediatric cancers and blood disorders in six countries (the Bahamas, Barbados, Jamaica, St. Lucia, St. Vincent and the Grenadines, and Trinidad and Tobago) by providing training and education, maintenance of local hospital-based pediatric oncology databases and treatment protocols, and establishing a subregional community of practice (²⁴24. The Hospital for Sick Children (SickKids). Capacity Building. [Accessed 28 February 2023]. Available from: https://www.sickkids.ca/en/care-services/centres/global-child-health/capacity-building/
https://www.sickkids.ca/en/care-services... ).

Since the launch of the GICC in 2018, substantial progress has been made in raising awareness of childhood cancer as a public health problem in LAC countries. By providing technical assistance to Member States, PAHO, St. Jude, and other collaborators have supported the Ministries of Health in holding 14 workshops to date (in-person/virtual) to establish a situational analysis, prioritize strategic activities, and develop a monitoring plan. To date, the Member States have been accompanied by 81 GICC projects and interventions at the national level on different topics of childhood cancer during the past 5 years (Figure 3).

Four years after becoming the first GICC focus country in the Region of the Americas, Peru has seen substantial progress in the implementation of the CureAll pillars (⁹9. Vasquez L, Maradiegue E, Rojas N, Montoya J, Zapata A, Ugaz C, et al. Catalyzing childhood cancer care in Peru after one year of the Global Initiative for Childhood Cancer. JCO Glob Oncol. 2021;7:187-189. doi:10.1200/GO.20.00601.
https://doi.org/10.1200/GO.20.00601... ). The country has opened new childhood cancer care centers (²⁵25. Pan American Health Organization. Hospital Daniel Alcides Carrión del Callao inaugura nueva Unidad Funcional de Oncohematología Pediátrica. [Accessed 28 February 2023]. Available from: https://www.paho.org/es/noticias/21-9-2022-hospital-daniel-alcides-carrion-callao-inaugura-nueva-unidad-funcional
https://www.paho.org/es/noticias/21-9-20... ), approved a new childhood cancer law in 2020 that includes social protection measures for families of children with cancer (²⁶26. Pan American Health Organization. Childhood Cancer Law in Peru: a history of the positive impact of the Global Childhood Cancer Initiative. [Accessed 28 February 2023]. Available from: https://www.paho.org/en/news/10-9-2020-childhood-cancer-law-peru-history-positive-impact-global-childhood-cancer-initiative
https://www.paho.org/en/news/10-9-2020-c... ), established a national workforce training plan, reduced the time to antibiotics administration in febrile neutropenic patients (²⁷27. Pan American Health Organization. Emergencia Pediátrica del Hospital Rebagliati logra reducir el tiempo de detección y atención de emergencias en niños con cáncer infantil implementando iniciativa de OMS. [Accessed 28 February 2023]. Available from: https://www.paho.org/es/noticias/13-5-2022-emergencia-pediatrica-hospital-rebagliati-logra-reducir-tiempo-deteccion
https://www.paho.org/es/noticias/13-5-20... ), and reduced the rate of abandonment of treatment (from 18.0% to 8.5%) at the national level (²⁸28. Ministry of Health of Peru. Minsa: Tasa de abandono al tratamiento de cáncer en niños y adolescentes disminuyó a 8.5%. [Accessed 28 February 2023]. Available from: https://www.gob.pe/institucion/minsa/noticias/543024-minsa-tasa-de-abandono-al-tratamiento-de-cancer-en-ninos-y-adolescentes-disminuyo-a-8-5
https://www.gob.pe/institucion/minsa/not... ).

Similarly, the Executive Secretary of Ministries of Health in Central America (Secretaría Ejecutiva del Consejo de Ministros de Salud de Centro América y República Dominicana) approved a subregional strategy to fight childhood cancer (²⁹29. Pan American Health Organization. Iniciativa Regional para la Atención Integral del Cáncer Pediátrico en los países de la Región SICA, 2019-2030. [Accessed 28 February 2023]. Available from: https://www.paho.org/es/documentos/iniciativa-regional-para-atencion-integral-cancer-pediatrico-paises-region-sica-2019-0
https://www.paho.org/es/documentos/inici... ). This regional validation of the importance of childhood cancer has contributed to accelerating the efforts to develop plans and interventions for childhood cancer at the national level. Panama (³⁰30. Pan American Health Organization. Guía para la detección temprana y atención oportuna de la sospecha del cáncer en niños y adolescentes 2021. [Accessed 28 February 2023]. Available from: https://www.paho.org/es/documentos/guia-para-deteccion-temprana-atencion-oportuna-sospecha-cancer-ninos-adolescentes-2021
https://www.paho.org/es/documentos/guia-... ) and the Dominican Republic (³¹31. Ministry of Health of the Dominican Republic. Manual de procedimiento de detección temprana de cáncer en niños, niñas y adolescentes. [Accessed 28 February 2023]. Available from: https://repositorio.msp.gob.do/handle/123456789/2281
https://repositorio.msp.gob.do/handle/12... ) achieved an increase in the timely detection of childhood cancer with national regulations and training of human resources. The special emphasis on the first level of care and the participation of civil society were fundamental factors for the successful implementation of these initiatives. Finally, we highlight the importance of developing national cancer control plans (NCCP) with a cost analysis to help policymakers and stakeholders in the prioritization of cost-effective interventions and efficient allocation of resources. The WHO Cancer Costing Tool is serving as a valuable resource for estimating the costs associated with different strategies and interventions and can aid in the evaluation and optimization of NCCP implementation in LAC.

Despite the national successes described in this report, the pace of the GICC implementation in LAC needs to accelerate if they are to achieve the ambitious goal they set together. The first years of disseminating the CureAll approach coincided with the COVID-19 pandemic, which led to delays in developing and implementing childhood cancer policies and programs in many countries, particularly in limited-resource settings. Moreover, it was observed that the COVID-19 pandemic in LAC caused severe disruptions in pediatric cancer treatments (³²32. Vasquez L, Sampor C, Villanueva G, Maradiegue E, Garcia-Lombardi M, Gomez-García W, et al. Early impact of the COVID-19 pandemic on paediatric cancer care in Latin America. Lancet Oncol. 2020;21(6):753-755. doi:10.1016/S1470-2045(20)30280-1.
https://doi.org/10.1016/S1470-2045(20)30... ).

Most countries successfully completed the first two phases of the CureAll implementation: situational analysis and planning. The shared next step in LAC is to approve the national childhood cancer regulations currently in development and implement adequately funded interventions.

Barriers and facilitators of the CureAll implementation in LAC

Of the 113 members of the GICC LAC working group, 50 participants completed Round 1 (response rate, 44%), and 29 completed Round 2 (response rate, 58%). Appendix 1 presents the demographic characteristics of participants in each round. The participants were from 15 different countries (Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Panama, Paraguay, and Peru). Most respondents were representatives of the Ministries of Health and public hospitals, followed by international and non-profit organizations. In Round 1, there were 13 barriers and 9 facilitators identified, and in Round 2, they added 4 barriers and 5 facilitators (Figure 4). Overall, the barriers and facilitators are presented with respective means and standard deviations in Appendices 2 and 3. Cronbach’s coefficient α was 0.87 and 0.73 for the barriers and facilitators, respectively, revealing internal consistency.

These findings reveal important insights into the barriers and facilitators to implementing CureAll from the perspective of the LAC implementers. The lack of a public budget assigned to childhood cancer activities, poor technical assistance and training, and the absence of a national CureAll coordinator were identified as the most salient barriers to implementation. These findings also suggest that implementing CureAll requires a concerted effort at the national level with substantial financial and technical support. On the other hand, these findings highlight that several facilitators can be properly leveraged to enhance the success of the CureAll implementation, with regional and global relevance. Adequate technical support and training in implementation strategies, the formation of working groups with national experts, protected time for the execution of activities, and the presence of personnel from the Ministry of Health dedicated to childhood cancer were identified as important facilitators. These findings provide valuable information for policymakers and practitioners interested in implementing CureAll or similar interventions in their own countries.

Although our study evaluated LAC as a whole, it is important to acknowledge that each country within this area possesses unique characteristics and contexts. By delving deeper into these diversities, we can gain valuable insights into how specific national realities can either facilitate or impede GICC implementation. For example, factors such as varying health care infrastructures, socioeconomic conditions, cultural norms, and policy frameworks can importantly influence the success and effectiveness of cancer control initiatives. In future research, we will explore these nuances further, conducting country-specific analyses to better comprehend the interplay between contextual factors and GICC implementation within individual LAC countries. This will allow for tailored strategies and interventions that can account for and address the specific challenges and opportunities present in each country, ultimately advancing cancer control efforts throughout LAC.

Strengths and limitations of the study

This study exhibits several noteworthy strengths that contribute to its importance to advancing our understanding of pediatric cancer health care in the LAC countries. First, the utilization of multiple data collection methods, including literature reviews, surveys, interviews, and analysis of health information systems, ensures a comprehensive and robust assessment of the subject matter. Second, the involvement of multiple stakeholders from the pediatric cancer health care system, such as representatives from Ministries of Health, public hospitals, international organizations, and non-profit organizations provide diverse perspectives and enrich the findings. Third, the engagement of actors from multiple countries in LAC allows for a broader representation of regional experiences and facilitates the identification of common challenges and opportunities. Lastly, the analysis of progress and factors related to implementation offers valuable insights into the effectiveness of current strategies and highlights areas for improvement. These strengths collectively enhance the reliability, depth, and relevance of the study, making it a valuable resource for policymakers, practitioners, and researchers invested in advancing pediatric cancer health care in LAC.

A limitation of this study is the lack of representation from Caribbean countries in the analysis. These countries may have unique challenges that were not captured in the findings. When interpreting the results, it should be noted that the findings may not be applicable to the Caribbean subregion. Further research is needed to explore the barriers and facilitators of implementing CureAll in these small island nations.

CONCLUSIONS AND RECOMMENDATIONS

Although substantial progress has been made toward addressing childhood cancer in LAC, it is important to acknowledge that there are still considerable challenges to overcome. A critical area that requires urgent attention is recognition and prioritization of childhood cancer as a public health issue by all Member States. Although some initial goals have been partially achieved regarding the PAHO childhood cancer strategic objectives, we are still far from reaching the ambitious targets set for 2030. To accelerate progress, there is an imminent need to increase the efforts in childhood cancer control. This includes prioritizing timely detection, ensuring access to essential diagnostics, developing resource-adapted treatment guidelines, improving palliative care services, and establishing robust systems for close follow-up of children and adolescents with cancer. Addressing these challenges head-on will be crucial in advancing the goals of the GICC and in ultimately improving outcomes for children and adolescents affected by cancer throughout LAC.

To maximize the effects of GICC implementation in the LAC countries, we propose the following recommendations for multiple stakeholders:

• Policymakers play a critical role in advancing childhood cancer control. It is crucial for policymakers to prioritize childhood cancer as a public health issue and allocate dedicated public budgets to support comprehensive prevention, diagnosis, treatment, and follow-up care. Establishing a national CureAll coordinator position can provide centralized leadership, which can ensure effective coordination of efforts across relevant departments. Collaboration with international organizations and experts can leverage technical assistance and training opportunities, enhancing the implementation of CureAll.

• Ministries of Health should integrate childhood cancer control into their national cancer control strategies. Allocating sufficient resources and forming working groups comprising national experts and stakeholders are essential steps. This facilitates collaboration, knowledge exchange, and capacity building among professionals involved in childhood cancer care. Additionally, ensuring protected time and dedicating personnel within the Ministry of Health to focus on childhood cancer activities can drive coordinated efforts and sustain progress.

• Health care professionals, particularly those working in pediatric oncology, have an essential role to play. Advocating for the implementation of CureAll and actively participating in its execution are key. Seeking training and technical support to enhance implementation strategies is important to ensure the delivery of high-quality care. Sharing best practices and experiences within national and Regional networks can foster continuous improvement in childhood cancer care and control.

• Non-profit organizations and international agencies are valuable partners in supporting the implementation of CureAll. These organizations should continue providing technical assistance, training, and financial support to countries throughout LAC. Collaborative efforts among non-profit organizations, international agencies, and national stakeholders can facilitate knowledge sharing, resource mobilization, and the development of sustainable childhood cancer control programs and initiatives.

By implementing these recommendations, stakeholders can collectively contribute to the successful implementation of CureAll, leading to improved childhood cancer outcomes in the LAC countries. These efforts require ongoing commitment, collaboration, and the mobilization of resources to ensure that every child with cancer receives timely and appropriate care. Together, we can make important strides in childhood cancer control, bringing hope and improved quality of life to children and families across the LAC subregion.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or the Pan American Health Organization (PAHO).

Acknowledgements.

The authors would like to acknowledge all the country teams (technical officers and consultants of the Ministries of Health, PAHO country office focal points, members of the academic societies, non-governmental organizations, and parents’ associations as part of CureAll Americas) of Argentina, Bolivia, Brazil, Colombia, Costa Rica, Chile, Dominican Republic, Ecuador, Honduras, Guatemala, El Salvador, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, and Venezuela. Our deepest gratitude to the regional and global collaborators (International Society of Pediatric Oncology; Latin American Society of Pediatric Oncology; Childhood Cancer International; International Atomic Energy Association; Consejo de Ministros de Salud de Centroamérica; the Caribbean Public Health Agency; and the Organismo Andino de Salud–Convenio Hipólito Unanue).

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