DISCUSSION
A clinician panel used the GRADE approach to produce evidence-based
recommendations for the surgical management of pediatric WT. Nineteen
recommendations were formulated to address preoperative, operative, and
postoperative concerns identified by surgeons practicing in
limited-resource settings. The guidelines address key questions
prioritized by the panel in the three phases of patient care. The panel
included multidisciplinary WT experts and maintained geographic and
gender balance. It produced recommendations based on the available
evidence and the identified priority outcomes and goals relevant in
limited-resource settings.
A few themes were identified throughout panel deliberations. In a
limited-resource setting, childhood tumor treatment is often effective
only if the patient presents early; therefore, access to timely therapy
is of paramount importance. In addition, a multidisciplinary childhood
cancer team incorporating radiologists, pathologists, oncologists,
radiation oncologists, and surgical specialists who discuss the case
prior to any surgical intervention is essential to ensure high quality
of care. Establishing a multidisciplinary team discussion or tumor
boards is a cornerstone of building capacity for pediatric oncology
care. One of the key limitations identified by the panel was a paucity
of evidence to address the selected questions. When evidence exists, it
is frequently of low quality. Well-designed, randomized controlled
trials and cost-effectiveness analyses are needed to examine the impact
of the included preoperative, operative, and postoperative interventions
on the outcome of WT.
Diagnostic capacity is limited in LMICs, and this continues to pose a
significant challenge to improving the outcomes of children with WT.
When there is no access to cross-sectional images, ultrasound and x-ray
images may guide therapy. The availability of pathologic analyses of
frozen sections may also be limited in LMICs. However, there is no
evidence to support the utility or cost-effectiveness of frozen sections
in WT surgery. The therapeutic interventions recommended by the panel
are affordable; most are considered standard of care across settings
with various resources and are not associated with increased risk to
patients. These recommendations are, therefore, practical and can serve
as a reference for practice standardization that may improve the
surgical outcomes of WT globally.