Cross-border partnership takes on ‘huge survival gap’ among children with leukemia
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Key takeaways:
- Implementation of a twinning program led to a significant improvement in 5-year OS rates among children with ALL.
- The program helped establish local partnerships that led to additional funding.
A partnership between health care systems along the U.S.-Mexico border led to clinically meaningful improvement in survival outcomes among children with acute lymphoblastic leukemia, study results showed.
The analysis of the cancer treatment training and access initiative — scheduled for presentation at ASCO Annual Meeting — revealed a significant increase in 5-year OS among children with standard- and high-risk ALL treated at a hospital in Tijuana, the investigators noted.
“Large disparities in access to high-quality cancer care often exist in low- and middle-income countries,” Julie R. Gralow, MD, FACP, FASCO, chief medical officer and executive vice president of ASCO, said in a press release. “The cross-border U.S.-Mexico partnership in this study illustrates collaborative strategies that can be put into place today that could greatly improve outcomes for children with cancer globally.”
Background
Incidence of childhood cancer has increased globally, but large disparities in survival exist depending on a child’s birthplace and that nation’s relative wealth, according to Paula Aristizabal, MD, MAS, hematologist-oncologist at Rady Children's Hospital-San Diego and associate professor of clinical pediatrics in the division of pediatric hematology/oncology at UC San Diego School of Medicine.
“Unfortunately, survival in low- and middle-income countries has not increased and improved at the same level as we have seen in high-income countries,” she told reporters during a press conference. “This has created a huge survival gap.”
To combat this disparity, Aristizabal and fellow researchers at Rady Children’s Hospital partnered with colleagues at Hospital General Tijuana in a process known as “twinning.”
The effort involves matching a center of excellence in a high-income country with one in a low- or middle-income country to share knowledge, technology and organizational skills, Aristizabal said.
The initiative’s goal is to build a sustainable, high-quality health care system equipped to manage leukemia care more effectively in a low- and middle-income country through consultation, collaboration and mentorship, she added.
“For our program in Mexico, we focused on building capacity and long-term sustainability,” Aristizabal said.
Methodology
Researchers based the program’s twinning model on the WHO Framework for Action Health Systems Strengthening.
The framework included modules on health service delivery, workforce, health information systems, access to essential medicines, financing and leadership/governance. Overall goals of the collaboration included improving patient outcomes and systems efficiency, ensuring timely access to care and social/financial risk protection.
The prospective analysis included 109 children (mean age, 7 years; 50.4% female) treated at Hospital General Tijuana, with 33% classified as having standard-risk ALL and 67% as having high-risk disease.
Researchers compared survival outcomes during the preimplementation period (2008-2012) with those in the postimplementation period (2013-2017). They also included sustainability indicators in their final analysis.
Key findings
Results showed significant improvement in all sustainability indicators during the post-implementation period, according to Aristizabal.
The health systems strengthening approach led to a fully staffed leukemia service with sustainable training programs and evidence-based, data-driven projects to improve clinical outcomes, in addition local partnerships that led to funding for medications, supplies and additional personnel, the investigators noted.
The collaboration also resulted in a significant increase in the 5-year OS rate among the entire study cohort compared with the preimplementation period (65% vs. 59%).
Further analysis revealed a significantly higher 5-year OS rate among patients with standard-risk ALL (100% vs. 73%) and high-risk ALL (55% vs. 48%) after implementation of the program.
Researchers reported decreases in mechanical ventilation days per 1,000 inpatient days (45 to 19), average antibiotic indication time (67.5 minutes to 35 minutes) and sepsis rates (30% to 5%), and an increase in adherence to pediatric blood products transfusion guidelines (39% to 80%).
Clinical implications
The twinning program based on the WHO Framework for Action model helped reduce leukemia survival disparities between the two centers, which are located less than 30 miles apart but on opposite sides of an international border, Aristizabal said.
The centers’ geographic proximity, along with the program’s mentoring efforts and data-driven projects to improve care, led to better clinical outcomes compared with the preimplementation period, she added.
“Capacity building resulted in the implementation of disease-specific treatment guidelines and a highly trained team [in Tijuana] able to provide high-quality supportive care,” Aristizabal said. “Sustained improvements in cancer outcomes in low- to middle-income countries are feasible with innovative cross-border programs.”
References:
- Aristizabal P, et al. Abstract 1502. Presented at: ASCO Annual Meeting; June 2-6, 2022; Chicago.
- ASCO. US-Mexico cross-border collaboration greatly improves pediatric leukemia survival (press release). Published May 25, 2023. Accessed May 25, 2023.
Perspective
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These findings shine a light on the importance of patients having adequate access to expert care when faced with acute leukemia. In fact, these findings demonstrate that access to the right care can improve survival outcomes in children with leukemia despite living in a low-and middle-income circumstances.
These results highlight the importance of receiving care at medical centers that are equipped to adequately treat a condition such as leukemia and that training and resources can bring centers without this expertise to a level that impacts patient survival. The partnership described in this abstract established a foundation at an underserved medical center in Mexico that became sustainable and improved a variety of health indicators including reduction in sepsis rates and adherence to pediatric transfusion guidelines.
The work makes clear that access to care is not just access to therapies. Adequate access also includes knowledge, technology, and skills of professionals.
This work dovetails with research supported by The Leukemia & Lymphoma Society that assessed equity and access to care among adolescents and young adults (AYA) with newly diagnosed acute lymphoblastic leukemia (ALL) in the United States.
This work demonstrated that AYAs with ALL had superior survival when treated at specialized cancer centers versus community hospital settings. The data also showed that age, race/ethnicity, and insurance type all independently influenced where patients received their care.
It is becoming more evident that we can do much more for our patients with the therapies that we now have, by ensuring access to quality care. We must continue to amplify this message and educate both patients and practitioners on why this issue matters and provide the training and partnerships that improve quality of care. With work such as described in this abstract, we will see improvements in survival for our patients.
Perspective
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Robert Cooper, MD
The issue of childhood leukemia outcomes in lower- and middle-income countries is important. Most people live in lower- and middle-income countries, so our ability to deliver similar types of chemotherapy to what is offered in rich countries is of utmost importance.
Pediatric leukemia is a great disease in which to test a multifocal approach to delivering complicated care to this population. Although there are newer, fancier medications, pediatric leukemia is very curable with older, less expensive medications. In order to deliver these medications most successfully, however, one needs to provide very aggressive supportive care.
Although the abstract does not break down which aspect of the care was most influential — access to medications, the ability to model care after the best clinical trial outcomes, or supportive care — one has to imagine it was some combination of these that showed the very impressive improvement and outcomes after implementation.
This study is a potential roadmap for providing first-world, complicated care outside a first-world setting. This group showed they had a defined intervention that addressed all of the needs of this population in terms of access, a plan to deliver the medications, and the ability to provide the supportive care necessary after providing medications for this curable disease.
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Aristizabal P, et al. Abstract 1502. Presented at: ASCO Annual Meeting; June 2-6, 2022; Chicago.
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