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Southeast Asia (SEA), a population of 700 million, faces a disproportionate pediatric cancer burden with approximately 16 000 new cases annually, ranking third globally for childhood cancer mortality rate.1 Regional disparities are stark, with SEA’s 5-year survival rate of 28.8% lagging significantly behind East Asia2 at 53.8%. This gap reflects a broader global inequity, in which high-income countries (HICs) achieve cure rates exceeding 80%, whereas low- and middle-income countries (LMICs), which comprise the majority of SEA nations (Table 1), consistently fall3 below 30%.Marked heterogeneity exists within SEA, where national oncology capacity and specialized resources and services remain largely limited, shaped by distinct sociocultural, socioeconomic, political, and health system contexts.4 These constraints directly impede access to timely and accurate diagnosis, essential medicines, treatments, and supportive care.4 Singapore and Malaysia, both HICs, have built strong pediatric oncology programs, whereas others continue to face critical deficiencies. The Philippines, an LMIC with restricted pediatric oncology programs, exemplifies these challenges, with 5-year overall survival ranging from just 20% to 50% and treatment abandonment rates reaching up to 80%.5 This global health feature explores the current performance of existing health systems in SEA countries and examines the importance of scaling to meet the pediatric oncology health care needs.Health care policy development varies widely across SEA, directly influencing observed incidence and mortality rates, spanning from universal health systems to minimal government coverage (detailed in Tables 1 and 2). This heterogeneity is reflected in cancer outcomes; for example, despite similar crude incidence rates of pediatric leukemia (the most common pediatric cancer), Singapore (incidence, 5.16 per 100 000; 95% uncertainty interval [UI], 2.28–9.39) and Timor-Leste (incidence, 5.11 per 100 000; 95% UI, 3.64–7.17) demonstrate markedly different mortality rates with 0.75 (95% UI, 0.64–0.86) compared with 3.20 per 100 000 (95% UI, 2.31–4.39), respectively (Table 1).6 This disparity reflects Singapore’s effective health policy and care delivery via its universal health care system, compared with Timor-Leste’s limited health expenditure per capita and absence of a formal national pediatric cancer care policy.7 These differences may be reflective of disparities in socioeconomic development, fiscal allocations, and overall health system capacity. Contributing factors include underdeveloped health care infrastructure, workforce shortages, limited cancer registries, and barriers to timely diagnosis, treatment, and supportive care. Regional policies are outlined in Table 2.Multidisciplinary health care teams are essential, yet many SEA LMICs face ongoing challenges in achieving this standard. A global survey of nurses revealed that LMICs often live with poor staffing ratios and limited physician oversight.8 Constraints on the oncology nursing workforce is because of limited advanced local training programs and insufficient professional support systems.8 Specific to SEA, there remains a lack of pediatric trained subspecialists across pediatric solid tumor units (PSTUs), with only 54% of specialized referral centers having access to pediatric trained radiologists and 41% to pediatric trained pathologists.1 Relatedly, radiation oncology residency training programs in the Philippines are limited because of limitations in access to advances such as computed tomography–guided image-guided radiation therapy and stereotactic treatments.9 As another example, disparities persist in Malaysia, where approximately 105 to 110 oncologists were practicing in 2018, equivalent to roughly 3 oncologists per 1 million population, most of whom were employed in the private sector.10 This reflects a longstanding imbalance in the distribution of specialized oncology personnel, with greater concertation in private institutions compared with the public sector.Availability and geographic distribution of pediatric oncology services in SEA vary widely, primarily reflecting disparities in resource allocation. For instance, the pediatric cancer mortality rate is higher in Lao People’s Democratic Republic, where a single PSTU serves 4 million children, compared with Malaysia, which has 8 PSTUs supporting 13.5 million children (1 PSTU per 1.7 million children).1 This limited availability of care facilities contributes to delays in diagnosis and treatment.The shortages in skilled workforce directly impact access to care. Patients in countries with archipelagic and mountainous terrain like the Philippines, Indonesia, Lao People’s Democratic Republic, and Vietnam face pronounced disparities in accessing therapy.11 In the Philippines, 72% of radiation therapy facilities are primarily located in Manila, requiring families from distant regions to travel several hours at a cost equivalent to 8 times the daily minimum wage.12 Many rural patients rely on local hospitals that lack specialized pediatric oncology services and trained personnel.13Families in most LMICs encounter barriers in accessing reliable medical information and guidance, including limited interaction with trained physicians who can offer appropriate support.14 Palliative care also remains underused across the region because of insufficient public and professional awareness as well as cultural norms, such as family-centered decision-making and reluctance to discuss end-of-life issues.15Inadequate insurance literacy has implications for catastrophic financial burden faced by families.5 For example, prior work has shown that numerous Filipino households enrolled in PhilHealth, a government-funded national health insurance program, did not file claims for illness, often because of a lack of awareness regarding available benefits.16 Such underuse suggests inefficiencies in program implementation, leaving vulnerable households without the financial protection to which they are entitled.16Across Indonesia, Malaysia, the Philippines, Thailand, and Vietnam, 24% to 68% of families affected by cancer experience financial catastrophe because of out-of-pocket health costs.17 Unlike the United States, where costs are often billed after care is delivered, many health systems in SEA rely on point-of-service payments (including upfront payment or settlement before discharge), which can limit access to essential care when families cannot pay at the time of treatment.5 Low-income families in Thailand and Indonesia often turn to unlicensed providers and traditional healers because of financial barriers.18 To manage costs, families rely on online fundraising platforms such as GoFundMe or Facebook.19 Consequently, many families discontinue medical treatment because of financial catastrophe.20Few countries in SEA have implemented survivorship programs that provide comprehensive lifelong care, including surveillance and management for late treatment effects, fertility preservation, psychosocial support, infection prevention, nutritional guidance, and palliative care. The extent of these programs varies across the region and is outlined in Table 2. The VIVA Foundation for Children with Cancer in Singapore is dedicated to improving survivorship and reducing late effects.21 The Philippines uses organizations like the Cancer Warriors Foundation to support survivors, alongside the Southern Philippines Medical Center and Philippine General Hospital, which focus on increasing survival rates.22,23 Malaysia’s Universiti Malaya Medical Centre also has a dedicated late effects surveillance clinic that offers annual follow-up care for adults.24 Other SEA countries have limited or nonexistent survivorship programs because of a lack of standardized guidance for long-term follow-up and insufficient transition protocols from pediatric to adult care.25Accurate cancer survival estimates are essential for effective policy planning and resource allocation, particularly in LMICs. Singapore was able to successfully develop a comprehensive pediatric oncology registry, in part because of facing fewer geographic barriers given the country’s small size.26 The country has made substantial investments in a robust cancer informatic system that is supported by dedicated staff to ensure effective operation.27 In contrast, even in countries with registries such as Vietnam and the Philippines, data availability is associated with limited administrative support, poor integration of registries into clinical workflows, and inconsistent patient records.28 Similarly, Indonesia’s Cipto Mangunkusomo National General Hospital developed a pediatric brain tumor registry and emphasized the need for trained data registry specialists to ensure accurate reporting.29 Strengthening local cancer registries is vital for improving pediatric cancer surveillance and system-wide accountability.Fellowship programs should integrate with existing education infrastructure while establishing clear career progression pathways as outlined by the Academic Model of Providing Access to Health Care Oncology model.30 Structured collaboration between HICs and LMICs within SEA can accelerate workforce development through knowledge transfer, joint training initiatives, and cross-institutional mentorship. The National Cancer Centre Singapore has established an academic program dedicated to providing training and mentorship in oncology to clinicians across Asia, enabling them to strengthen cancer care standards within their home countries.31 Additional intraregional oncology workforce training collaborations include formal networks such as the South-East Asia Cancer Grid and South-East Asia Regional Childhood Cancer Grid, regional training platform like ACTIVE 2.0, and professional organizations such as the Southeast Asian Federation of Organizations for Medical Physics.32,33 Adequate compensation, along with institutional efforts to address burnout and high workload, is critical for retaining the oncology workforce in these regions. Indonesia has implemented targeted financial incentives for specialist physicians practicing in remote districts, offering up to Indonesian Rupiah 35 million per month (∼$2200 US dollars), which is twice the compensation of standard public sector roles.34Promoting health literacy is essential in early identification of health issues and encourages timely health care–seeking behavior. Lao People’s Democratic Republic has used village health volunteers to act as cultural brokers across minority communities.35 Vietnam has adopted a similar model in which patients felt more supported through a specialized community-based program.36 Patient navigators within health care facilities and communities can also significantly improve patient understanding by addressing cultural beliefs surrounding alternative treatments and social stigma, thereby promoting timely treatment initiation.Satellite facilities offer a promising approach to improving access to services for children residing in rural areas. The satellite clinic network seen in Myanmar can be implemented in other LMICs to expand access across similar terrains in the region.37 However, even in upper-middle-income countries like Malaysia, where pediatric oncology has expanded through dedicated centers, geographic barriers still constrain access and require families to travel across states for treatment.38 Mobile outreach programs could complement existing facilities, ensuring that specialized pediatric oncology care becomes more geographically accessible.37The implementation of virtual platforms for tumor boards and consultations can mitigate geographic barriers and enhance communication in rural settings. Diagnostic capacity can be strengthened through the adoption of digital pathology programs, which have been successfully used in rural regions and Vietnam.39 Asynchronous virtual tumor boards can provide critical support to pediatric oncology teams, particularly in cases in which local clinical expertise is limited.40 Integration with electronic health records enables comprehensive patient tracking and outcome monitoring across the care network.41Efforts are needed to expand health care coverage and protection.42,43 For example, Singapore’s strong health system provides universal health coverage that enables continuous care across the disease trajectory.44 Although with some limitations, the introduction of universal health care in Thailand demonstrates measurable impact, as evidenced by increased health care use among patients who are low-income and chronically ill, while improving cancer detection and survival rates.45 Coverage should include hospital- and home-based palliative care as well as nonmedical expenses because financial hardship is a leading barrier to treatment completion.46 Additionally, improving health literacy initiatives, such as targeted insurance education and patient navigation support, can help families better navigate and file claims for illness, thereby reducing the financial burden of cancer treatments. Beyond medical expenses, families face substantial indirect costs, such as transportation, lodging, and lost income, which compounds financial strain. In rural India, cancer care improved through the government-funded Ayushman Bharat program, which provides transportation allowances, accommodation support, and food services to assist low-income households.47 Risk pooling mechanisms can distribute costs across larger populations, whereas targeted subsidies address specific barriers facing vulnerable groups.48 Payment mechanism should incentivize appropriate care coordination and quality outcomes rather than volume-based service delivery.49Pediatric oncology integration within national cancer control plans requires dedicated budget allocations and governance structures. Singapore has demonstrated one of the strongest commitments to pediatric cancer policy in the region, with standardized treatment protocols contributing to an overall survival rate of 72.4% and long-term survivorship50 of 80.4%. Their policy framework can serve as an example for responsibilities across health system levels and establish quality standards.Global partnerships have proven essential for expanding health infrastructure across SEA. Eight of 11 SEA countries participate in the St. Jude Global Asia Pacific Regional Program, facilitating clinical and educational resource exchange.51 Successful collaborations between St. Jude and the Philippines, Myanmar, Cambodia, and Singapore demonstrate that effective partnerships extend beyond funding to encompass training, research, and sustainable health care system development.51 Similarly, Myanmar has partnered with Boston’s Children Hospital to provide overseas specialty training opportunities for nurses in an effort to expand the specialized oncology workforce.52 Regional coordination through Association of Southeast Asian Nations health cooperation frameworks can amplify individual country partnerships while promoting South-South learning opportunities.53 Clinicians and policymakers in LMICs often experience difficulty implementing care models derived from HICs because of resource limitations.8 Strategic collaborations between local, private, national, regional, and international stakeholders are crucial for strengthening the funding and implementation of health care systems. However, strategic partnerships must balance external support with sustainable capacity building to avoid creating dependency relationships.Direct comparisons among SEA countries are limited because of varying stages of progress in national research efforts, heterogeneity in available published data and gray literature, and perhaps most importantly, immensely different health care contexts.4 A comprehensive search of relevant published abstracts and articles indexed in PubMed, the World Health Organization, World Bank Group, 2023 Global Burden of Disease databases, and individual country’s news articles was conducted to ensure the inclusion of the most current evidence. Countries such as Singapore and Malaysia have a more extensive body of published research in this field, as are most HICs. Consequently, developments within their health systems are more prominently represented. Indeed, the limited availability of published research from LMICs likely reflects differences in resources, research capacity, and national health priorities rather than an absence of need.Disparities in pediatric cancer outcomes across SEA result from systemic challenges, including underdeveloped cancer registries, limited survivorship programs, and fragmented national control frameworks, compounded by resource scarcity, geographical isolation, and financial burdens. SEA HICs with superior oncologic survival outcomes demonstrate that effective pediatric cancer control is attainable through deliberate policy design and phased implementation. To improve oncologic outcomes in the SEA region, each country’s national, local, and private stakeholders should commit to (1) integrate pediatric oncology into national control plans with dedicated governance, (2) establish satellite clinics and digital platforms to address geographic barriers, and (3) expand coverage to include nonmedical costs that limit access, delay treatments, and drive treatment abandonment. The SEA region’s children deserve comprehensive, coordinated action that converts political will into measurable improvements in survival and family well-being.
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ประเด็นที่เกี่ยวข้อง: Acute Lymphoblastic Leukemia research · Childhood Cancer Survivors' Quality of Life · Advances in Oncology and Radiotherapy
บทบาทของนักวิจัยและสถาบันไทย
Teeradon Treechairusame · Siriraj Hospital
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