Improving treatment of children with acute lymphoblastic leukemia in developing countries through technology sharing, collaboration and partnerships

Abstract

Cure rates for pediatric acute lymphoblastic leukemia differ markedly in higher- and lower-income countries due to disparate hospital infrastructure and resources. Where means are limited, treatment-related mortality is higher and compliance may be suboptimal. Upfront risk assignment is aimed at individualizing therapy according to presenting features in order to avoid over- or under-treatment. However, the necessary technical resources and expertise are not always readily available. The authors provide suggestions for management of childhood acute lymphoblastic leukemia in developing nations. To improve patient care locally, the authors recommend that communication technology be used to sustain partnerships between sponsoring and partner pediatric oncology programs. The aims of these collaborations should be to prioritize resources, identify existing problems and reduce treatment intensity and hence treatment-related morbidity and mortality in patients at lower risk of relapse.

Keywords::

• acute lymphoblastic leukemia
• lower- and higher-income countries
• minimal residual disease
• partner institution
• reduced intensity chemotherapy
• risk-directed therapy
• sponsor institution

Financial & competing interests disclosure

This paper was funded by St Jude Children’s Research Hospital, Memphis, TN, USA. Sharon Naron (St Jude Children’s Research Hospital) provided scientific editing assistance, funded by St Jude Children’s Research Hospital. This work was supported in part by Cancer Center Support (CORE) grant P30 CA021765-30 from the National Institutes of Health and by the American Lebanese Syrian Associated Charities (ALSAC). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Childhood acute lymphoblastic leukemia (ALL) is a curable disease, but access to modern treatment is not uniform and early and late therapy-related complications are important causes of morbidity and mortality.

• Cure rates among children with ALL differ markedly in high-income countries and developing countries.

• Experience has shown that when intensive chemotherapy protocols developed in centers of excellence are used in lower-income countries without adjustment to local conditions, early death rates may be prohibitively high.

• Once the diagnosis of ALL is established, the authors strongly favor treatment in a pediatric oncology unit staffed by skilled multidisciplinary teams, preferably using protocol-based therapy.

• Current communication technology offers ways to strengthen professional collaboration between sponsor institutions and distant partner sites, creating collegial working groups to discuss patients’ presenting features, risk classification, protocol assignment, response to therapy and overall progress.

• Sponsor institutions may facilitate the transfer of biotechnology, for example, the determination of minimal residual disease at key points in treatment, and help introduce ALL protocols featuring risk-adapted therapy.

• Patients with ALL at lower risk of relapse may be effectively and safely treated with less-intensified protocol-directed chemotherapy, mainly as outpatients, with reduced toxicity and at lower cost.

• In the view of the authors, the collaborative model used with their Brazilian and Egyptian colleagues to transfer technology, expertise and know-how to best meet the needs of the partner institution is succeeding beyond initial expectations.