1 INTRODUCTION

In recent years, Italy has recorded a substantial increase in its foreign population: as of January 1, 2023, there were 5 million foreigners legally residing in Italy, equal to 8.6% of the total population, with an annual increase of 20,000 people (+0.4%/year).¹ This has brought new challenges for the National Health System (NHS), also considering the phenomena of patients traveling outside their country of residence to receive medical care.^2-11

Non-citizen people seeking medical care, including asylum seekers and refugees of all ages, is an increasing challenge for high-income countries. In particular in the field of pediatric oncology—where the personalization of care is crucial, in addition to the overall attention given to the patient and family—we have found ourselves facing new medical and regulatory problems, but also cultural, economic, linguistic, and social issues.^{12, 13}

This paper aims to describe the complexity of the clinical management of foreign minors suffering from cancer, through the clinical experience of the Pediatric Oncology Unit of the Fondazione IRCCS Istituto Nazionale dei Tumori di Milano.

2 METHODS AND RESULTS

Foreign patients under the age of 18 treated at our unit in 2023 along with their clinical characteristics were prospectively registered for the purpose of this study.

In total, 50 foreign patients under 18 years were treated in 2023 at our unit (22% of all new admissions in 2023). Of these, 32 were foreigners already residing in Italy, and 18 were patients who came to Italy specifically to receive cancer treatment (migrants).

Data were compared with those retrieved retrospectively from the unit's clinical database for the years 2003 and 2013: the percentage of foreign patients treated in our unit has grown over the years. In 2003, there were 17 (8% of the patients), of whom eight were residents and nine were migrants for treatment, while in 2013 there were 33 (12% of cases), of whom 16 were residents and 17 migrants.

Table 1 contains the main clinical characteristics of the 50 foreign patients treated in 2023. In particular, among the 18 patients who migrated for treatment, 13 arrived at our unit with advanced disease (five with metastatic disease and eight with relapsed disease).

Many different critical aspects were reported. The need for economic support, language barriers, and socio-cultural barriers were major challenges for both residents and migrants. The problem of covering health expenses and access to the NHS was a major challenge for migrant patients. In Italy, the NHS fully covers medical expenses for most clinical situations, and in particular for cancer patients treated in public hospitals. Foreign patients who reside in Italy are registered with the NHS and receive treatment in the same way as Italian citizens. Those who migrate for treatment may have different options to access the NHS, depending on their country of origin (if it is part or not of the European Community). The process to obtain a visa for medical treatment and registration with the NHS may require various weeks.

A further issue was the problem of compliance with treatment, reported in 10/18 migrants.

Patients were offered personalized psychological counseling, an aspect that is of high importance for families who, in addition to the trauma of the childhood cancer diagnosis, face the destabilizing situation of treatment in a foreign country.

A major issue concerns the coverage of all expenses. The heterogeneity of patients by age and size of the entire family unit, tumor type, and treatment plan (in terms of duration and type of therapy) makes it difficult to calculate the economic burden of a single patient. We can approximately calculate a cost of between 50,000 and 100,000 euros for an average patient who receives multidisciplinary treatment for a 6-month period. Depending on the situation, these costs are covered by the NHS or, at least in part, by associations and charities. Costs for food, accommodation, supportive services, and others may be around 10,000 euros for an average period of 6 months (costs always covered by associations and charities).

3 DISCUSSION

This paper aims to generate interest around the complexity of the clinical management of foreign minors suffering from cancer. This is an emerging problem, that is, in our series 22% of the patients admitted to the unit in 2023 were foreigners (with the two different categories, residents from Italy, or patients who arrived from abroad specifically for cancer treatment). In fact, globalization has led to an increase in health migration (particularly, from countries with low healthcare expenditure to specialized care centers). Moreover, recently, the pediatric oncology community had to address the need to care for children evacuated from Ukraine (an activity that our unit has been involved in since the early days of the crisis).^{14, 15} It should be noted that our experience is not directly related to either the Global Initiative for Childhood Cancer promoted by the World Health Organization (WHO) and the St. Jude Children's Research Hospital¹⁶ or the Safer Ukraine project launched by the St. Jude Global.¹⁷

Our study has highlighted some important aspects: (i) patients who migrate for healthcare reasons often arrive with advanced disease or relapse; (ii) migrant patients may often have problem of compliance with treatment (maybe related to major language and cultural barriers, which can make it difficult to understand the proposed treatments); (iii) multiple social issues complicate the care for patients and their families; (iv) practical challenges such as medical insurance and expenses, added to basic needs in families with limited economic resources.

While representing a local experience that may not translate to all nations and centers, our integrated strategy model with collaboration with various associations, charities, and services serves as an example of the approach to the social and cultural differences among foreign patients.

International initiatives directly focusing on the cooperation between different national health systems and cancer centers are necessary to better address the issue of trans-border migration in pediatric cancer. The European Reference Network on Paediatric Cancer (ERN PaedCan) (https://paedcan.ern-net.eu/), for example, aims to “reduce inequalities in childhood cancer survival by providing high-quality, accessible, and cost-effective cross-border healthcare to children and adolescents with cancer, regardless of where they live.” The development of a dedicated committee within the framework of the International Society of Paediatric Oncology (SIOP) could be a challenging attempt to address this issue globally.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.