Outcomes of Childhood Acute Lymphoblastic Leukemia Treated with Modified BFM-2009 Protocol Using Measurable Residual
Sanjeev Khera1, M K Safal Muhammed2, Rajiv Kumar3
1Department of Pediatrics, Army Hospital (Research & Referral), Delhi, India. kherakherakhera@gmail.com.
Indian Pediatrics
|February 12, 2026
Summary
Adapting chemotherapy protocols, like the modified Berlin-Frankfurt-Munster (BFM)-2009, significantly improves treatment outcomes for childhood acute lymphoblastic leukemia (ALL) in low-income countries. This approach enhances survival rates and reduces relapse in pediatric cancer patients.
Area of Science:
- Pediatric Oncology
- Hematology
- Clinical Research
Background:
- Standard chemotherapeutic protocols from high-income countries often yield suboptimal results in low- and lower-middle-income countries (LMICs).
- Acute lymphoblastic leukemia (ALL) is a common childhood cancer, and effective treatment protocols are crucial for improving survival rates.
- The Berlin-Frankfurt-Munster (BFM) protocol is a widely used regimen for childhood ALL.
Purpose of the Study:
- To analyze the treatment outcomes of a modified Berlin-Frankfurt-Munster (BFM)-2009 protocol in children diagnosed with acute lymphoblastic leukemia (ALL).
- To evaluate the efficacy and safety of adapting a standard chemotherapy protocol for the specific context of a tertiary care referral center in Northern India.
- To assess the impact of risk stratification on treatment outcomes in pediatric ALL patients within a LMIC setting.
Main Methods:
- A retrospective study was conducted involving 166 children newly diagnosed with ALL.
- Patients were treated with a modified BFM-2009 protocol employing a risk-stratified approach.
- Follow-up data were collected and analyzed to determine event-free survival (EFS) and overall survival (OS).
Main Results:
- The study observed a 36-month event-free survival (EFS) of 95.7% for standard-risk, 83% for intermediate-risk, and 76.9% for high-risk patients.
- Overall survival (OS) at 36 months was 96.5% (SR), 85% (IR), and 79% (HR), indicating good outcomes across risk groups.
- Prednisolone poor response (PPR) and intermediate/high-risk (IR/HR) stratification were associated with poorer EFS, highlighting key prognostic factors.
Conclusions:
- Adapting international chemotherapy protocols, rather than strictly adopting them, is essential for improving outcomes in childhood ALL within LMICs.
- The modified BFM-2009 protocol demonstrated favorable treatment results in the Indian tertiary care setting, suggesting successful adaptation.
- Risk stratification and monitoring treatment response markers like PPR are critical for optimizing care and improving survival in pediatric ALL patients in resource-limited settings.
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