The majority of children with cancer in developing countries are diagnosed too late, when advanced disease is already present, and many more die without ever being diagnosed. Various factors contribute to the diagnostic delay (Fig. 2.2).

The site of the solid tumor will determine if the presentation is early or late. If it is in the close proximity of a vital structure such as the airway, it may present earlier, as compared to a tumor in the parenchyma or pleura. A high proliferation rate may also ensure that a tumor is noted earlier, e.g., Burkitt lymphoma or acute leukemia. Systemic symptoms, like night sweats or fever may prompt a visit to the doctor and lead to a cancer diagnosis or may be misdiagnosed with common infection.

In young babies it may be difficult to note neurological signs and symptoms early, since the tumor can grow to a significant size due to the pliable skull bones and open fontanelle. Adolescents may not want to discuss their health problems with their parents for various reasons, including cultural reasons or privacy issues.

Parents may not recognize symptoms as possible early warning signs of childhood cancer. In the African setting, because of difficulties in accessing health care and also because of religious and social beliefs, parents often first seek help from traditional healers. Therefore awareness campaigns and education in the community are extremely important, as well as ensuring access to health care and specified referral pathways. However, a South African study showed that the biggest reason for delay in diagnosis in their setting was the failure of health care practitioners to recognize the warning signs. Thus health care practitioners should be adequately trained regarding the suspicion and early diagnosis of childhood cancer. Awareness and outreach campaigns among health care practitioners are i mportant to keep the focus on childhood cancer.

The early warning signs of childhood cancer are present in about 85 % of childhood cancers, although they are not specific for cancer. They are easy to remember and easy to identify on history or clinical examination. Every country should have simple pamphlets or posters of early warning signs to be distributed among health care practitioners and the community (Fig. 2.3). A study performed in South Africa showed that after an awareness campaign using the “Saint Siluan early warning signs of childhood cancer” was started, an increased number of new cancer cases were diagnosed (Fig. 2.4). The Saint Siluan signs have been adopted by SIOP-PODC (International Society of Pediatric Oncology’s Committee on Developing Countries) and the International Confederation of Childhood Cancer Parent Organization (ICCCPO).

Another example of a list of warning signs is “CHILD CANCER,” an acronym which is also endorsed by international childhood canc er organizations (Table 2.1).