O2148: Current Realities of Wilms Tumor Burden and Therapy in Ghana

Background: Wilms tumor (WT) disease-free survival at 2 years alarmingly approached 44% between 2005-2014 in Ghana. A collaborative study among Ghana, Malawi and Cameroon in subsequent years revealed only a slight improvement to 50% event-free survival compared to ~90% at 4 years in high-resource countries. This study aimed to uncover socioeconomic and clinical factors that continue to lead to preventable WT death in Ghana.

Methods: WT patient records (August 2014-June 2022) at Korle-Bu Teaching Hospital (KBTH; Accra, Ghana) were reviewed retrospectively. Demographics, social determinants of health, clinical course, and tumor characteristics were analyzed. Groups were compared using t-tests and Pearson Chi-square tests, along with multivariate Cox logistic regression.

Results: 127 WT patients (65 female) were identified (median age, 44 months [IQR 25-66]). Distance greater than 40 km from KBTH associated with delayed referral from outside hospitals (p=0.03). 48 patients (38%) presented with distant metastasis (75% lung, 25% liver), which associated with caregiver employment in the informal economy (p=0.003) and larger tumor size at presentation (p=0.002). Hypoalbuminemia also associated with larger tumor size (p=0.02) and metastasis (p=0.009). Although 84% of tumors regressed with neoadjuvant chemotherapy, larger initial size associated with incomplete R1/R2 resection (p=0.046). 110 patients had nephrectomy: 6 tumor rupture, 5 tumor spill, 11 lymphadenopathy, and 33 R1/R2 residual disease, which negatively impacted survival (p=2.7x10-5). Hypoalbuminemia (p=0.005) and post-operative stage IV (p=1.2x10-5) also negatively impacted survival. 22 patients (17%) abandoned treatment (13 stage IV), with 6 eventually returning for care. 11 patients (50%) abandoned treatment before nephrectomy and were considered deceased. 11 patients (50%) abandoned treatment after nephrectomy, with 7 lost to follow-up (LTFU). Among patients presenting with metastases, 43% died, but 8% were LTFU. If no metastases, 28% died (4% LTFU). Multivariate analysis of distant metastasis at presentation, tumor size, distance from KBTH, employment status, histopathological risk status, and post-operative distant metastasis demonstrated a statistically significant association with survival (χ2 = 23.1%, p=0.002). Excluding LTFU, 2- and 4-year overall survival were 61.6% and 56.3%, respectively. Including treatment abandonment, relapse, and death as negative events, 2- and 4-year event-free survival were 53.9% and 52.5%, respectively.

Conclusion: Although WT survival in Ghana has improved, social factors impacting secure employment, distance from KBTH, and adherence to care predisposed patients to greater tumor burden, poorer nutritional status, R1/R2 resections, LTFU, and lower survival.