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Predictors of outcome and methodological issues in children with acute lymphoblastic leukaemia in El Salvador
Miguel Bonilla1, Sumit Gupta, Roberto Vasquez
1Paediatric Oncology, Benjamin Bloom National Children's Hospital, San Salvador, El Salvador.
Insights
In El Salvador, socioeconomic factors like income and parental education improved survival for standard-risk childhood leukemia patients. Disease severity was key for high-risk cases, highlighting the need for tailored interventions in low-income countries.
Area of Science:
- Pediatric Oncology
- Global Health
- Epidemiology
Background:
- Most childhood cancer cases occur in low-income countries (LICs).
- Risk factors for childhood acute lymphoblastic leukemia (ALL) in high-income countries may not apply to LICs.
- Understanding unique survival predictors in LICs is crucial.
Purpose of the Study:
- To identify predictors of survival for children with ALL in El Salvador.
- To examine demographic, disease-related, socioeconomic, and nutritional variables.
- To inform targeted interventions for childhood leukemia in resource-limited settings.
Main Methods:
- Retrospective analysis of 443 children under 16 diagnosed with ALL between 2001-2007.
- Utilized the El Salvador-Guatemala-Honduras II treatment protocol.
- Assessed event-free survival (EFS) and overall survival (OS) using Cox proportional hazards models.
Main Results:
- Standard-risk 5-year EFS was 56.3%, high-risk was 48.6%. Standard-risk 5-year OS was 77.7%, high-risk was 61.9%.
- For standard-risk patients, higher monthly income and parental secondary education predicted better EFS.
- For high-risk patients, higher initial white blood cell count predicted worse EFS; socioeconomic factors were not predictive.
Conclusions:
- Socioeconomic status significantly impacts EFS in standard-risk childhood ALL patients in El Salvador.
- Disease-related factors are primary predictors for high-risk ALL.
- Event-free survival (EFS) should be the primary outcome measure in LIC studies to improve understanding and interventions.
Background:
Most children with cancer live in low-income countries (LICs) where risk factors in paediatric acute lymphoblastic leukaemia (ALL) developed in high-income countries may not apply.
Methods:
We describe predictors of survival for children in El Salvador with ALL. We included patients <16 years diagnosed with ALL between January 2001 and July 2007 treated with the El Salvador-Guatemala-Honduras II protocol. Demographic, disease-related, socioeconomic and nutritional variables were examined as potential predictors of event-free survival (EFS) and overall survival (OS).
Results:
260/443 patients (58.7%) were classified as standard risk. Standard- and high-risk 5-year EFS were 56.3 ± 4.5% and 48.6 ± 5.5%; 5-year OS were 77.7 ± 3.8% and 61.9 ± 5.8%, respectively. Among standard-risk children, socioeconomic variables such as higher monthly income (hazard ratio [HR] per $100 = 0.84 [95% confidence interval (CI) 0.70-0.99; P=0.04]) and parental secondary education (HR = 0.49, 95% CI 0.29-0.84; P = 0.01) were associated with better EFS. Among high-risk children, higher initial white blood cell (HR per 10×10(9)/L = 1.03, 95% CI 1.02-1.05; P<0.001) predicted worse EFS; socioeconomic variables were not predictive. The difference in EFS and OS appeared related to overestimating OS secondary to poor follow-up after abandonment/relapse.
Conclusion:
Socioeconomic variables predicted worse EFS in standard-risk children while disease-related variables were predictive in high-risk patients. Further studies should delineate pathways through which socioeconomic status affects EFS in order to design effective interventions. EFS should be the primary outcome in LIC studies.
