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SA med students failing to recognise childhood cancer's early warning signs

CancerFinal-year SA medical students remember only six of at least 20 early warning signs of childhood cancer, found a University of the Witwatersrand study. Medical schools needed to reassess their methods of training, said Dr Jennifer Ann Geel, who led the study.

The Times reports that they are especially weak at diagnosing brain cancer‚ the second most common form of childhood cancer‚ something described as “particularly concerning” by a research team from the medical school at Wits University.

Dr Jennifer Ann Geel, at the department of paediatrics, faculty of health sciences, University of the Witwatersrand, Johannesburg, South Africa and the division of paediatric haematology and oncology, department of paediatrics and child health, Charlotte Maxeke Johannesburg Academic Hospital, said the findings were troubling because early diagnosis was vital in treating cancer and preventing complications such as cognitive and learning difficulties and irreversible brain damage.

Five-year survival rates of South African children with cancer are poor – around 50%‚ compared with more than 80% in high-income countries – and Geel said under-diagnosis may be partly to blame. Only around 700 cases were reported annually‚ while global guidelines suggested the number should be between 900 and 2,500.

“It has been estimated that two-thirds of South African children with cancer do not reach an appropriate specialist centre‚ and many of the children who present to a paediatric oncology unit do so with advanced disease‚” said Geel.

The report said early warning signs of childhood cancer‚ such as unexplained bleeding and fever‚ easy bruising‚ fatigue‚ loss of weight and appetite‚ change in balance‚ an enlarging head and aching joints‚ were easily mistaken for common and less severe illnesses.

Geel’s team asked 84 final-year medical students at Wits to recall early warning signs of childhood cancer. They averaged a score of six. Then they presented them with a list of 20 symptoms and asked them to say which were linked to the disease (all of them were). In the second test they averaged 70%.

Geel said: “It may be inferred that medical students are trained to recognise signs and symptoms rather than being able to recall them from memory‚” adding that this may be linked to multiple-choice exams becoming more common.

She said medical schools needed to reassess their methods of training students to recognise childhood cancer. “Improving survival rates of children with cancer will require a thoughtful‚ multi-pronged approach‚ and increasing awareness at medical school represents the foundation of this undertaking.”

Background. The reported incidence of childhood cancer in upper-middle-income South Africa (SA) is much lower than in high-income countries, partly due to under-diagnosis and under-reporting. Documented survival rates are disturbingly low, prompting an analysis of potential factors that may be responsible.
Objectives. To determine final-year medical students’ level of knowledge of early warning signs of childhood cancer and whether a correlation existed between test scores and participants’ age, gender and previous exposure to a person with cancer.
Methods. A two-part questionnaire based on the Saint Siluan mnemonic, testing both recall and recognition of early warning signs of childhood cancer, was administered. The Mann-Whitney-Wilcoxon test was used to assess differences in continuous and count variables between demographic data, experience and responses, and Fisher’s exact test and Spearman’s rank correlation coefficient were used to determine correlations between demographic data, previous contact with persons with cancer and test scores. A novel equality ratio was calculated to compare the recall and recognition sections and allowed analysis of recall v. recognition.
Results. The 84 participants recalled a median of six signs each (interquartile range 4 – 7) and correctly recognised a median of 70% in the recognition section, considered a pass mark. There was no correlation between participants’ age, gender, previous contact with a person with cancer and recognition scores. Students with previous exposure to a person with cancer had higher scores in the recall section, but this did not achieve statistical significance. Students were able to recognise more signs of haematological malignancies than central nervous system (CNS) malignancies.
Conclusion. The study demonstrated a marked inconsistency between recall and recognition of signs of childhood cancer, with signs of CNS malignancies being least recognised. However, the majority of students could recognise enough early warning signs to meet the university pass standard. Although this study demonstrated acceptable recognition of early warning signs of childhood cancer at one university, we suggest that long-term recall in medical practitioners is poor, as reflected in the low age-standardised ratios of childhood cancer in SA. We recommend increased ongoing exposure to paediatric oncology in medical school and improved awareness programmes to increase early referrals.

Jennifer Ann Geel, Brent T Stevenson, Rebecca B Jennings, Lisa E Krook, Sinead J Winnan, Bracha T Katz, T J Fox, Lukhanyo Nyati

[link url=""]The Times report[/link]
[link url=""]SA Medical Journal abstract[/link]

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