Key-words:
Central nervous system cancers - Democratic People's Republic of Korea - neurosurgery
- pediatrics
Introduction
Over the past several decades, substantial improvements have been made in treatment
outcomes for children with cancer who live in high-income countries (HICs).[[1]] Meanwhile, the same progress has not been translated to low-income and middle-income
countries (LMICs), where outcomes remain poor and 90% of children at risk of developing
childhood cancer live.[[1]] Childhood cancers can rapidly progress to fatality without timely diagnosis and
treatment and in contrast to adult cancers, cannot be prevented by reducing risks
in lifestyle, it is imperative that efforts to expand and improve access to and quality
of health care includes cancer care for this vulnerable group.
With central nervous system (CNS) cancers ranking as the most frequent solid tumors
and the leading cause of cancer-related deaths in children and adolescents, it is
important to recognize that the incidence of this disease varies considerably among
different regions.[[2]] Very little data about pediatric brain and CNS tumors in LMICs are available, suggesting
a lack of accessibility or limited capacity to treat these conditions.[[1]] However, treatment of childhood cancer in LMICs has demonstrated to be cost-effective
according to the World Health Organization's Choosing Interventions that are cost-effective
criteria, and due to finite resources and competing health priorities, identifying
and quantifying childhood cancer disease burden is critical in informing health policy
decisions.[[1]]
In this study, we chose to study the epidemiology of CNS cancers in the Democratic
People's Republic of Korea (DPRK).[[3]],[[4]] As surgical treatment can often prolong lives and even prevent premature deaths
from these cancers, further analysis of current surgical capacity can inform the path
to meeting these critical pediatric surgical needs.
Methods
We extracted the prevalence, incidence, deaths, and disability-adjusted life years
(DALYs) associated with CNS cancers in individuals under the age of 20 from the 2017
Global Burden of Disease (GBD) study from the Institute for Health Metrics and Evaluation
(IHME). DALYs which signify the number of healthy life years lost due to ill health,
disability, or early death. Economic impact was calculated from DALYs using methods
by Dalal and Park.[[5]]
Results
According to the IHME estimates, out of all solid cancers among pediatric population
in the DPRK, CNS cancers such as brain and spinal cord tumors are responsible for
the highest DALYs, prevalence, incidence, and number of deaths [[Table 1]]. In 2017, North Korea had 952 total cases of CNS cancer with 189 new cases arising
during the year [[Table 2]]. They estimated 80 deaths associated with this disease. The IHME estimates that
6334 DALYs were lost due to brain and spine cancers in this population.
Table 1: List of cancers in decreasing order of disability.adjusted life years, prevalence,
incidence, and death in North Korea
Table 2: Disability-adjusted life years, incidence, prevalence and deaths of top three pediatric
cancers in North Korea
Liver cancer is ranked as 2nd highest by DALYs, with 1471 health life years lost.
Although low in incidence and prevalence, this cancer has a poor prognosis and high
mortality rate. DPRK had estimated 588 cases of liver cancer with 24 cases, and 20
deaths associated with the disease. Next on the list is kidney cancer with estimated
730 health life years lost, 70 new cases, and 9 deaths.
To provide some context, we compared the DPRK's prevalence, incidence, DALYs and deaths
associated with brain and nervous system cancer to the estimates from South Korea,
Cuba, and Myanmar [[Table 3]]. The numbers were adjusted for population, signifying number per 100,000 people.
Table 3: Disability-adjusted life years, incidence, prevalence, and deaths associated with
brain and nervous system cancer in Democratic People’s Republic of Korea, Republic
of Korea, Cuba, and Myanmar in 2017
According to the IHME database, North Korea and South Korea had the similar rates
of new cases of brain and nervous system cancer in 2017. During that same year, North
Korea had a prevalence of 952 total cases (37 cases per million), and South Korea
had a higher rate of 58 cases per million. The higher prevalence in the ROK may be
due to longer survival of the children with CNS cancers given wider availability of
chemotherapy and radiotherapy. However, the death rates and DALYs associated with
the disease differ drastically. The IHME estimated three deaths (per million) and
249 healthy life years lost due to the disease in North Korea. The same disease is
associated with one death (per million) and 95 years of healthy life lost in South
Korea.
In 2017, Cuba had 55 cases of brain and nervous system cancer with eight new cases.
Myanmar had the lowest prevalence and incidence of 21 and 6, respectively. However,
the IHME database estimated Cuba and Myanmar to have the highest mortality rates and
DALYs among the four countries. Four (per million) children died due to the disease,
and 329 health life years were lost. The low prevalence may be related to the relative
higher mortality rate, i.e., there are not that many survivors from these conditions.
The loss of GDP as the result of the DALYS from these conditions in North Korea is
estimated to be about $4.3 million in 2017. This was calculated by multiplying the
DALYs with the nation's GDP per capita of the year. The GDP per capita for 2017 was
$685 according to the United Nations database.[[6]] The value represents what each person would have contributed to the economy had
they survived the disease.
Discussion
Brain and spinal cord cancers are the most common solid tumors in children and the
second most common childhood malignancy.[[7]] Treatment and prognosis depend on the type, location, and child's age and health.
Despite brain cancers being one of the most common causes of death in children in
LMICs, there is a clear paucity of surgical capacity to address the needs. According
to Dewan et al., there are around 330 pediatric neurosurgeons caring for 1.2 billion
children in low-income countries.[[8]] They also report that more than 85% of pediatric neurosurgeons around the world
practice in high-and middle-income countries. To improve the delivery and outcomes
of surgery in low-income countries, it is important to appreciate the existing gaps
in pediatric surgical services.
The IHME database estimates suggest about a three-fold higher mortality rates associated
with brain and nervous system cancer in North Korea, Cuba, and Myanmar when compared
to a higher income country such as ROK. This may seem intuitive given that in LMICs,
these cancers are generally found later in their course, and more difficult to treat
due to advanced diseases. However, we must not discount the importance of surgical
care in diagnosing and treating cancer in the LMICs where advanced diagnostics, chemotherapeutic
drugs, and radiation therapy are virtually nonexistent. Given the importance in surgical
care in these settings, it is particularly worrisome that <8% of the pediatric population
in LMICs had access to surgical care in 2017.[[9]]
According to a study that looked at the global comparison of pediatric surgery workforce
and training, the number of pediatric surgeons has a positive correlation with gross
domestic product (GDP) in countries with a GDP per capita <US $20,000.[[10]] Another study notes that LMICs only have 19% of the global surgical workforce.[[11]] Lack of appropriate human resources for the surgical care of children in low-income
countries prevents timely and adequate intervention, adding to the disease burden.
The DPRK uses an extensive network of over 9,000 health-care facilities that function
at levels ranging from central, provincial, county, to rural.[[12]] For the 2016–2020 Medium Term Strategic Plan, it was proposed to improve specialized
medical care by providing specialized medicine and equipment to advance diagnostic
and treatment methods.
As classifying health facilities is valuable for allocating resources to different
levels of the healthcare system, the Optimal Resources for Children's Surgical Care
2019 guidelines present a classification system for the delivery of pediatric surgical
care.[[13]] As seen in [[Table 4]], levels of children's surgical care (basic, intermediate, and complex/advanced)
were suggested according to the variable complexity of children's surgical conditions.
Cancers of every form, which often involve highly specialized care, were recommended
to be treated at facilities offering complex/advanced levels of surgical care by the
2017 Disease Control Priorities Project (DCP3). As suggested by the Global Initiative
for Children's Surgery, this treatment is advised to be performed at facilities of
the referral level [[Table 5]].
Table 4: Levels of care based on surgical conditions, recommended care level availability
by facility type, and examples of care at each level from the 2018 guidelines for
different levels of care by the Global initiative for children’s surgery
Table 5: Description and examples of different healthcare facilities in low-income and middle-income
countries based on the classification system used in 2017 disease control priorities
project and the 2018 guidelines for different levels of care by the global initiative
for children’s surgery
In contrast to surgical care for emergency cases such as for traumatic injuries, in
general, pediatric brain and spinal cord cancers do not present as medical or surgical
emergencies. Neurological symptoms such as paralysis or worsening vision are easily
recognized and drive families to seek medical care. In a country like DPRK, with a
population of 25 million living in a relatively small geographically contained country,
a single-center specializing in pediatric brain and spinal cord cancers may be sufficient
as a starting point. It should be able to handle the 200 or so new cases expected
each year.
The Okryu Pediatric Hospital was built in October of 2013 in Pyongyang to provide
latest medical service for children. In this six-storied hospital, treatment rooms,
operation rooms, and sick wards are furnished with some of the latest medical equipment.
Although official number of pediatric surgeons in North Korea is not available, one
of our authors (DSH) has worked alongside pediatric neurosurgeons at the Okryu Pediatric
Hospital over the last several years [[Figure 1]]. He estimates 1 pediatric neurosurgeon at Okryu Hospital with 5 more in various
stages of training. Although tasked with providing the most complex level of pediatric
care for the nation, this hospital experiences the typical challenges found in similar
hospitals in LMICs: routine reusing of surgical supplies, limited imaging capabilities,
inconsistent emergency transport, and variable availability of critical medications,
among others.
Figure 1: Dr. David Hong at Okryu Pediatric Hospital
As the capacity (both technical and volume) for the care of pediatric brain and spinal
cord cancers are strengthened at the Okryu Pediatric Hospital, then the Hospital will
likely serve as the primary training center for additional pediatric neurosurgeons
who can staff the provincial hospitals to manage simpler cases. Ultimately, only the
most complex and difficult cases should be referred to the national hospital.
Our study is timely. The DPRK is planning to strengthen the surgical care capacity
nationally per their 2016–2021 MTSP for the Health Sector. The WHO is partnering with
the DPRK Ministry of Public Health to support surgical system strengthening in the
DPRK. A key project specifically targets improving pediatric surgical care, and our
study may help in better understanding the surgical needs for pediatric cancers.
Conclusions
Given the large burden of brain and CNS cancers among all pediatric cancers in the
DPRK, scaling up and strengthening surgical services for children is an essential
component to improving care of pediatric CNS cancers in the DPRK. Childhood cancers
are time sensitive, and early diagnosis and treatment are vital in ensuring improved
survival for the vulnerable pediatric cancer patient population. Fortunately, the
need is being prioritized by the DPRK and there are external partners with shared
interests. The current MoPH project with the support of the WHO country office should
serve as a pilot project with an intent to strengthen surgical care nationally. We
hope the international community will step up and help fund this important initiative.
Limitations
As primary data were unavailable, the data used for this study were estimates from
the GBDs, injuries, and risk factors (GBD) studies coordinated by the IHME. While
there is criticism of the lack of transparency in the methods and complex statistical
methods used to calculate the data, no better credible dataset for the DPRK exists.
