@article {632904,
	title = {Estimating the total incidence of global childhood cancer: a simulation-based analysis},
	journal = {Lancet Oncol},
	year = {2019},
	month = {2019 Feb 26},
	abstract = {BACKGROUND: Accurate estimates of childhood cancer incidence are important for policy makers to inform priority setting and planning decisions. However, many countries do not have cancer registries that quantify the incidence of childhood cancer. Moreover, even when registries do exist, they might substantially underestimate the true incidence, since children with cancer might not be diagnosed. We therefore aimed to provide estimates of total childhood cancer incidence accounting for underdiagnosis.

METHODS: We developed a microsimulation model to simulate childhood cancer incidence for 200 countries and territories worldwide, taking into account trends in population growth and urbanicity, geographical variation in cancer incidence, and health system barriers to access and referral that contribute to underdiagnosis. To ensure model results were consistent with epidemiological data, we calibrated the model to publicly available cancer registry data using a Bayesian approach in which the observed data are fixed and the model parameters (cancer incidence and probabilities of health system access and referral) are random variables. We estimated the total incidence of childhood cancer (diagnosed and undiagnosed) in each country in 2015 and projected the number of cases from 2015 to 2030.

FINDINGS: Our model estimated that there were 397 000 (95\% uncertainty interval [UI] 377 000-426 000) incident cases of childhood cancer worldwide in 2015, of which only 224 000 (95\% UI 216 000-237 000) were diagnosed. This finding suggests that 43\% (172 000 of 397 000) of childhood cancer cases were undiagnosed globally, with substantial variation by region, ranging from 3\% in western Europe (120 of 4300) and North America (300 of 10 900) to 57\% (43 000 of 76 000) in western Africa. In south Asia (including southeastern Asia and south-central Asia), the overall proportion of undiagnosed cases was estimated to be 49\% (67 000 of 137 000). Taking into account population projections, we estimated that there will be 6{\textperiodcentered}7 million (95\% UI 6{\textperiodcentered}3-7{\textperiodcentered}2) cases of childhood cancer worldwide from 2015 to 2030. At current levels of health system performance, we estimated that 2{\textperiodcentered}9 million (95\% UI 2{\textperiodcentered}7-3{\textperiodcentered}3) cases of childhood cancer will be missed between 2015 and 2030.

INTERPRETATION: Childhood cancer is substantially underdiagnosed, especially in south Asia and sub-Saharan Africa (including western, eastern, and southern Africa). In addition to improving treatment for childhood cancer, health systems must be strengthened to accurately diagnose and effectively care for all children with cancer. As countries expand universal health coverage, these estimates of total incidence will hopefully help guide efforts to appropriately increase health system capacity to ensure access to effective childhood cancer care.

FUNDING: Boston Children{\textquoteright}s Hospital, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Harvard Medical School, National Cancer Institute, SickKids, St Jude Children{\textquoteright}s Research Hospital, and Union for International Cancer Control.},
	issn = {1474-5488},
	doi = {10.1016/S1470-2045(18)30909-4},
	author = {Ward, Zachary J and Yeh, Jennifer M and Bhakta, Nickhill and Frazier, A Lindsay and Rifat Atun}
}
