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Childhood Acute Lymphoblastic Leukemia Survival in Western Kenya: Reduction in Early Deaths and Treatment Abandonment
Gilbert Olbara1, George Bogonko2, Festus Njuguna2
1Directorate of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya.
Insights
Implementing targeted interventions significantly improved event-free survival for childhood acute lymphoblastic leukemia (ALL) in Kenya. Strategies included modified treatment and enhanced support, reducing abandonment and improving outcomes for pediatric cancer patients.
Area of Science:
- Pediatric Oncology
- Hematologic Malignancies
- Clinical Trial Design
Background:
- Previous studies at Moi Teaching and Referral Hospital (MTRH) indicated poor outcomes for children with acute lymphoblastic leukemia (ALL), including low event-free survival (EFS), high treatment abandonment, and induction mortality.
- These findings necessitated the development and implementation of targeted strategies to address the root causes of poor treatment outcomes.
Purpose of the Study:
- To evaluate the impact of specific intervention strategies on the treatment outcomes of childhood acute lymphoblastic leukemia (ALL) at MTRH.
- To compare the EFS, relapse rates, treatment abandonment, and induction mortality before and after the implementation of these interventions.
Main Methods:
- A retrospective review of medical charts for 123 children diagnosed with ALL between 2017 and 2020 (post-intervention cohort) was conducted.
- Data from this cohort were compared with 136 children diagnosed between 2010 and 2016 (pre-intervention cohort).
- Survival analysis was performed using the Kaplan-Meier method to compare outcomes between the two cohorts.
Main Results:
- Three-year EFS estimates significantly improved from 18% to 41% (p=0.0001) after intervention.
- Relapse and progressive disease rates decreased from 26% to 16% (p=0.04136), and treatment abandonment dropped from 24% to 14% (p=0.03318).
- While induction mortality decreased from 24% to 17% (p=0.198), this did not reach statistical significance. Children aged 1-9 years and those with a white blood cell count <50 × 10^9/L showed better EFS.
Conclusions:
- Systematic data collection and locally adapted interventions effectively reduced treatment failure and improved survival rates for childhood ALL.
- Strategies such as improving access to asparaginase and enhancing insurance coverage through education and philanthropy are recommended for similar settings.
- Further research is needed to refine risk stratification for newly diagnosed ALL patients in resource-limited environments.
Background:
An earlier study on children diagnosed with acute lymphoblastic leukemia (ALL) at Moi Teaching and Referral Hospital (MTRH) in Kenya reported a low event-free survival (EFS), excess treatment abandonment, and high induction mortality. Based on these observations, our team focused on implementing strategies to reduce the causes of poor outcomes.
Intervention:
The interventions were designed to reduce toxic deaths while maintaining the efficacy of treatment. The strategies included are as follows: (1) substituting asparaginase for doxorubicin in induction; (2) enhanced supportive care, increased access of antibiotics and blood products; (3) enhanced social and financial support for all underserved patients at the time of diagnosis. Our study compared childhood outcomes of ALL treatment before and after implementation of these intervention strategies at MTRH.
Methods:
We retrospectively reviewed the medical charts of 123 children diagnosed with ALL between 2017 and 2020 (cohort 2). Their clinical profiles and treatment data were collected and subsequently compared to that of 136 children diagnosed between 2010 and 2016 (cohort 1) before the implementation of the interventions above. Survival analysis was compared using the Kaplan-Meier method.
Results:
Three-year EFS estimates improved from 18% to 41% (p = 0.0001). Relapse and progressive disease decreased from 26% to 16% (p = 0.04136), and the abandonment decreased from 24% to 14% (p = 0.03318), respectively. Deaths in induction decreased from 24% to 17% (p = 0.198). Children between 1 and 9 years and those with white blood cell (WBC) count <50 × 109/L had better EFS (50% vs. 26%, p < 0.001 and 50% vs. 24%, p = 0.017, respectively).
Conclusions:
Use of systematically generated data and application of locally adapted interventions led to a reduction in treatment failure and increased survival. Improved access to asparaginase by working with local suppliers and increased insurance coverage through parental education and philanthropies are strategies that could be adopted by centers in low- and middle-income countries. More efforts are required to improve risk stratification for newly diagnosed ALL patients.
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