For students who are keen to learn more about oncology in the developing world, it can be difficult. Although just as prevalent as in the UK, resources are dramatically reduced and it is thought that only 5% of sufferers have access to treatment facilities. That said, there is enormous opportunity in our African hospitals to learn more about a specific type of the disease - Burkitt's lymphoma.
Burkitt's lymphoma research shows the potential for leading to tremendous payoffs across all areas of cancer research.
Named after Denis Parsons Burkitt, who in the late 1950’s mapped the specific geographic distribution of this disease across Africa, this rare and aggressive cancer of the lymphatic system has one form that can only be found in Africa and is the most common malignant tumour across the continent.
The National Cancer Institute believes that a global perspective is clearly desirable in studying cancers. By comparing and analysing cases in Africa, researchers in all countries are benefitting from the cooperation and understanding gleaned from studies.
The three main types of Burkitt's lymphoma are:
- Endemic: this mainly occurs in equatorial Africa. It is the most common malignancy of children in this area. It is linked to malaria and Epstein-Barr virus.
- Sporadic: occurs outside of Africa. It is also linked to Epstein-Barr but not to such a great degree.
- Immunodeficiency associated: This is invariably linked to HIV or the use of immunosuppressive drugs.
"The cells in endemic and sporadic forms are B lymphocytes that have rearranged immunoglobulin genes and contain one of three translocations of the proto-oncogene c-myc. The most common translocation is from the long arm of chromosome 8 to chromosome 14" Patient UK
Interestingly there has also been suggestion that arboviral infection (transmitted by insect vectors) and tumour-promoting plant extract-derived herbal remedies are co-factors.
Endemic Burkitt's lymphoma can cause extremely painful and disfiguring swelling of the jaw, eyes, face and abdomen. It attacks quickly and can be fatal within weeks if not treated promptly and appropriately. A tumour can double in size within 18 hours!
The most common presentation is a swelling of the affected jaw / bone as well as rapidly enlarging, non-tender lymph nodes in the neck / jaw. However, depending on where it has spread it can also affect the bowel and the lymph nodes in the tummy (abdomen), causing symptoms such as pain, feeling sick (nausea) and diarrhoea. It can also involve the bone marrow, spleen and liver, and sometimes may spread to the brain and spinal cord.
Other symptoms, known as B symptoms, include night sweats, unexplained high temperatures and weight loss.
Who does it affect
Burkitt's lymphomas account for fewer than 10% of adult diffuse lymphomas, but account for the majority of childhood B-cell lymphomas.
Patient.co.uk reports that the disease most commonly affects children, but it can occur in adults. They also note that it is significantly more common in sub-Saharan Africa, where it accounts for approximately one half of childhood cancers. It is also evident in South America, North Africa and the Middle East.
Within Tanzania, three (3) out of 100,000 children will be affected by Burkitt’s Lymphoma, at any one time. The incidence peaks at around 5-8 years old and is more common in boys.
Treatment & problems
Response to chemotherapy of BL is normally rapid, with noticeable tumour shrinkage within 48 to 72 hours of the first dose of the first cycle. By the beginning of the second treatment cycle, visible or palpable tumour is normally gone. A 2010 Trial for Burkitt's Lymphoma improved 2 year survival from 15% to 73%.
The key thing is to treat it quickly, however this is often delayed.
Although facial asymmetry is noticed very early by the parents, they may delay presentation by seeking out traditional healers or dental care.
Lack of education about the rapid growth of BL is not the only problem. Patients also do not visit hospital because of the cost of journeying there. In most cases they present when the cancer is advanced, which can often mean the tumours are untreatable.
For those that do make it to the hospital in time, there is the further problem of treatment. Outside of Dar es Salaam, hospitals do not offer chemotherapy. If Burkitt's Lymphoma is diagnosed then private hospitals or a referral to Dar are your only option. A treatment cycle can cost the equivalent of a years salary - more than most Tanzanian's can afford.
There is one cancer institute in the country that accepts referrals. Based in Dar it runs a programme funded by charitable donations. Here the standard Burkitt’s Lymphoma treatment revolves around a combination of three drugs, Cyclophosphamide, Vincristine, and Methotrexate (systemic and intrathecal). This combination is repeated for a total of six cycles. Lack of education and finances causes more problems here - patients often fail to attend all cycles and the cancer can then return. When this happens survival rates dramatically diminished. Often the hospital will keep patients in for months to make sure that they receive all medication.
The big hope is that a vaccine for Epstein Barr virus as this seems intrinsically linked to the disease.
What experience have student's gained?
“A small boy with swelling of the orbit and jaw as well as severe anaemia and fever. The doctor suspected either retinoblastoma or Burkitt's lymphoma. The child was sent to Dar es Salaam for further treatment” Kirsty (Nursing)
"The staff are very friendly and are obviously doing the best they can with very limited resources.
"I spent my second week in the paediatric oncology department, the only such department in Tanzania. It was very overcrowded with three patients to each bed. I got involved in a wide variety of things ranging from checking the patients’ observation and drug charts on ward rounds to assisting in bone marrow aspirations and lumbar punctures." Hannah Townsend
"The treatment highlighted perfectly the difference between health care and delivery" Rory (medic)
"Burkitt’s Lymphoma is something that I first heard about, vaguely, in the infectious disease module of my undergraduate degree. It’s a childhood cancer, linked to reactivation of a latent Epstein-Barr virus and with a genetic component that means it’s seen only in African populations. I’d never seen it or expected to see it in Britain, even with the time I’ve spent hanging around the haematology wards. Here, it’s the single most common cancer diagnosis. A few times when I’ve been on the ward, I’ve assisted with the giving of intrathecal chemotherapy to the paediatric patients, many of whom have Burkitt’s. On my first day, there was one child who didn’t need to be restrained. I hate having to hold children down for procedures, but I hate it more when I don’t have to. If a child lets a doctor put a needle into their spinal cord without making any effort to struggle, there’s something very very wrong." Beth (medic)
"Working in Tanzania provided enormous insight into the difficulties of providing an oncology service in Africa. It also gave me an opportunity to observe an entirely new range of conditions and procedures. Until now I had only ever read about Burkitt’s Lymphoma, retinoblastoma and Kaposi’s sarcoma in textbooks. Here they are an everyday occurrence.” Charlotte (medic)
Although a radiography student, David Evans wrote a fantastic blog about cancer care in Africa. Follow the link to read his article.