Professor Thomas Lehrnbecher, from Johann Wolfgamg Goethe-University in Germany, speaking about invasive fungal infections during chemotherapy and how to treat them. Photo: VIVA Foundation for Children with Cancer

The 11th St. Jude-VIVA Forum in Paediatric Oncology

By Ms Cher Boon Meng, 

Clinician-Scientist Unit, NUHS

The annual St. Jude-VIVA Forum (SJVF) is a collaboration between St. Jude Children’s Research Hospital (St. Jude) in Memphis, Tennessee, USA, and the Singapore-based charity VIVA Foundation for Children with Cancer. It is the leading regional conference in paediatric oncology which aims to share knowledge and foster collaboration among paediatric oncologists. Held on March 1 to 5, the 11th SJVF welcomed 240 delegates from around the world.

This year’s SJVF brought news of improved treatments in a variety of paediatric cancers. The first day focused on leukaemias and lymphomas. Dr Tanja Gruber from St. Jude updated delegates on an improved protocol for treatment of infant leukaemia, a disease with notoriously dismal outcomes. Professor Wing Leung from Miltenyi Biotec in the United States then shared some of the ways that clinicians can improve the results of bone marrow transplantation by selecting for specific immune cell types and omitting others. Professor Dario Campana from the Department of Paediatrics at NUS held the stage with updates on cellular therapy, giving examples of trials conducted here at the National University Cancer Institute, Singapore.

Day 2 was dedicated to solid tumours and it also featured news of huge improvements in solid cancer treatments. We journeyed 20 years with Professor Alice Yu from the University of California in San Diego, USA, and Chang Gung Memorial Hospital, Taiwan, from the development of the antibody treatment ch14.18 through pre-clinical studies, and finally to its approval as Unituxin in 2015 for high-risk neuroblastoma. Dr Amar Gajjar from St. Jude introduced new therapeutic targets in brain cancers and Professor Carlos Rodríguez-Galindo from St. Jude wrapped up the event with information about improved treatment protocols for germ cell tumours.

The SJVF aims to address the disparity in cancer treatment between developed and developing nations. Thus, the Pre-Forum Workshop was instituted in the second year. A mainstay since then, it is a chance for doctors to come together to discuss and solve issues that developing Asian nations face. This year, Dr Krista Lea Francisco from the Department of Paediatrics at NUS introduced the Paediatric Early Warning Score (PEWS) used at NUH to aid in early detection of clinically deteriorating patients. PEWS serves as a common language in the medical team, and empowers nurses to notify doctors of early signs of deterioration before critical deterioration occurs. Its implementation in NUH led to a 50% decrease in admission to the paediatric intensive care unit. This lecture spawned a very lively discussion among the participants, as it was a simple yet powerful way of improving patient care even in resource-constrained countries.

On the second day of the Pre-Forum Workshop, the participants heard from Dr Ratha Mlis of Cambodia. A young paediatric oncologist, she returned from training in France only to be told by paediatric hospitals in Cambodia that “now is not the time to treat cancers”. Undeterred, she went to adult oncology hospitals and found a home at Calmette Hospital, where she set up a small paediatric oncology unit in 2014. Dr Mlis’ sharing triggered a heart-warming outpouring of encouragement, advice and tips from doctors of other developing countries. The workshop concluded with the formation of several cross-border collaborative groups, each for a different cancer type.

From the Pre-Forum, we were reminded that the success of cancer treatment depends on much more than mere therapy. In developing countries, socioeconomic and cultural factors greatly hinder treatment. Upfront treatment refusal or abandonment are also common problems: parents are unable to afford chemotherapy, or have difficulties accessing hospitals. For retinoblastoma especially, successful treatment usually requires enucleation (removal of the eyeball), and parents are understandably opposed to that. Even among clinicians, there is a dire lack of knowledge regarding cancer in children, with some not knowing that childhood cancers exist, or that it can be treated. This leads to delayed diagnosis and treatment, compromising cure.

In addition to the Pre-Forum, the SJVF also gave rise to several collaborative groups: the VIVA-Asia Working Group, focusing on leukaemia; the VIVA-Asia BMT Group, focusing on stem cell transplantation, and the VIVA-Asia BST Group, which looks at brain and solid tumours. At the forum, each working group held closed meetings for deeper discussions in their respective areas. Since 2015, we have also held the Nursing Symposium and CCF-VIVA Family Learning Exchange, the former for nurses to share experiences and techniques in supportive care, and the latter for families of our patients to meet with experts and other families. This year also saw the inaugural session of the South-east Asia Retinoblastoma Symposium, which will be another mainstay of the SJVF.

There is an increasing need for paediatric oncologists to don several hats, what Professor Mathew Wilson from St. Jude summarised as a “paediatric-ophtho-onco-radio-patho-logist”. Thus, the 11th SJVF invited clinicians from non-oncology specialties to share their expertise in problems that crop up during cancer treatment. As part of the Pre-Forum Workshop, Professor Paul Anantharajah Tambyah, from the Department of Medicine at NUS, gave a talk on tuberculosis (endemic in Asia) and how it complicates cancer treatment. Dr Wang Shi from the Department of Pathology at NUS, shared with participants some of the pitfalls in diagnosing lymphoma.

The South-east Asia Retinoblastoma Symposium also heard from several NUH clinicians: Dr Choong Chih Ching from the Department of Diagnostic Imaging on imaging of retinoblastomas, Dr Gangadhara Sundar from the Department of Ophthalmology on enucleation, and Associate Professor Nga Min En from the Department of Pathology on retinoblastoma pathology. The 11th SJVF ended on an optimistic note, with repeats of improved treatment protocols and higher remission rates across many types of cancers.

The foundation has come a long way since 2005, when Mrs Jennifer Yeo from VIVA Foundation, Professor Pui Ching-Hon from St. Jude, and Associate Professor Allen Yeoh from the Department of Paediatrics at NUS conceived it with the aim of improving childhood cancer treatment in Asia. Through the efforts of paediatric oncologists around the world, and the kindness of donors, the SJVF has achieved this aim over the last decade. It will continue to do so, and perhaps the day will come, when Prof Pui’s vision of a “100% cure” becomes reality.

The South-east Asia Retinoblastoma Symposium 2017, held at NUS’ Centre for Translational Medicine, was attended by paediatric oncologists, pathologists, and ophthalmologists from Singapore, South-east Asia, and the United States. Photo: VIVA Foundation for Children with Cancer