Childhood Acute Lymphoblastic Leukemia survival in Western Kenya: reduction in early deaths and treatment abandonment

Abstract

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.