Childhood Cancer Survivorship: Nurses in Low- and Middle-Income Countries Poised to Lead

An early example of childhood cancer survivorship surveillance in high-income countries (HIC) began in 1972 with the Late Effects Study Group (LESG), 12 pediatric oncology treatment facilities in the United States, Canada, and Western Europe, sharing data on second malignancies posttreatment.1 By 1983, the first childhood cancer survivorship clinic led by a pediatric oncology nurse practitioner, Wendy Hobbie, RN, MSN, CRNP, FAAN, was established at the Children’s Hospital of Philadelphia in the United States.2 This initiative demonstrated nursing’s inherent role in ensuring that the end of treatment does not mean the end of care and a nurse’s ability to lead this follow-up service. In general, care for children/adolescents with cancer in low- and middle-income countries (LMIC), where greater than 80% of this population lives, is focused on disease survival. Comprehensive treatment is challenging, particularly for cancers requiring high-cost chemotherapies, substantial supportive care, or specialized surgery, for example, leukemias and central nervous system tumors. Formal survival surveillance programs are rare mainly due to factors such as shortages of specialized pediatric oncologists and nurses in general, limited training in survivorship care, and nonexistent government financial support. Nevertheless, childhood cancer treatment in many LMIC has long been supported by HIC partners such as French childhood cancer centers (eg, Gustave Roussy Institute, Villejuif), the Francophone-African Group of Pediatric Oncology,3 and St Jude Children’s Research Hospital in the US and centers in Latin America.4 Although in many LMIC, there is a shortage of nurses in general and a lack of specialization training in pediatric oncology nursing, in all but 3 countries, there are significantly more nurses overall than physicians. This means that existing nurses caring for children/adolescents across LMIC are well-positioned to take the lead on survivorship surveillance. They know and have cared for these young patients who have survived cancer. They have a position of trust with the families and in many cases ties to the nongovernmental organizations (NGOs), for example, Childhood Cancer International (a parent and survivor NGO in 90 countries5), which have supported the families of these children/adolescents since diagnosis to avoid treatment abandonment. With minimal training, the experienced nurses in many of these LMIC centers can follow the lead of Hobbie and colleagues from years ago and begin to coordinate basic survivorship screening and surveillance following new guidelines for use in limited resource settings.6 Hobbie2 mentions the nursing role in survivorship as clinician-caregiver, educator, and researcher. Although the role of nurse practitioner is not formally recognized in many LMIC, the current nursing workforce in this subspecialty in several countries includes nurses with this scope of practice in acute care settings.7 The time is overdue for the growing population of LMIC childhood cancer survivors to have access to surveillance and support for the physical/mental health and psychosocial consequences of childhood cancer treatment. The United Nations Sustainable Development Goal 3 states “Ensure healthy lives and promote well-being for all at all ages.”8 For survivors of childhood cancer everywhere, this begins at the end of treatment with a formal plan for survivorship surveillance in alignment with the patient’s disease and treatment and a transition to adult care with a professional who is informed about the risks and prevention strategies for long-term childhood cancer survivors. Pediatric oncology nurses across LMIC are well poised to lead initial foundational survivorship programs in collaboration with local NGOs, multidisciplinary colleagues in cancer centers (including local adult healthcare professionals to sustain follow-up care), and international partners, thus emulating the inaugural efforts of pioneer Hobbie and subsequent nurse leaders in childhood cancer survivorship care.