Translation of cure for acute lymphoblastic leukaemia to all children

Analysis of outcomes and prognostic factors of acute lymphoblastic leukemia patients treated by MCP841 protocol: A regional cancer center experience

Background:

A dramatic improvement in the survival of acute lymphoblastic leukemia (ALL) patients in the last three decades has been observed. MCP 841 protocol is an old but effective tool with tolerable toxicities. The objective of this study was to estimate the relapse-free survival of ALL patients treated uniformly with MCP 841 protocol on the basis of various prognostic factors.

Materials and Methods:

The study design was retrospective and it was conducted in a regional cancer center of Northwest India. Three hundred and ten ALL patients who underwent treatment with MCP 841 protocol and regular follow-up for up to 5 years were selected for this study. Relapse-free survival was calculated by Kaplan–Meier analysis and Cox regression analysis was used to calculate the hazards ratio (HR) using Statistical Package for the Social Sciences (SPSS) software for windows version 20.0.

Results:

Fifty-four percent patients were <15 years of age and 69% were males. 53.2% patients were in remission at the end of 5 years of starting the treatment. Relapse-free survival at 5 years by Kaplan–Meir analysis for B-cell ALL was 62% [HR 0.67 {95% confidence interval (CI) 0.47-0.95}] with patients with unknown lineage taken as reference] while for T cell it was 28% [HR 1.41 (95% CI 1.19-1.63), P 0.001]. Patients with total leukocyte count (TLC) <1 lakh/cmm at presentation, relapse-free survival was 68% and those with TLC >1 lakh/cmm had 41% survival [HR 2.14 (1.76-2.48) with, P < 0.001].

Conclusion:

MCP 841 protocol is a useful tool for the treatment of ALL in children when more aggressive protocols can not be used.

Influence of dihydrofolate reductase gene polymorphisms rs408626 (-317A>G) and rs442767 (-680C>A) on the outcome of methotrexate-based maintenance therapy in South Indian patients with acute lymphoblastic leukemia

PURPOSE

The most common cause of treatment failure in acute lymphoblastic leukaemia (ALL) is the relapse. Genetic polymorphisms of dihydrofolate reductase (DHFR) enzyme affect the response to methotrexate (MTX) treatment. Inter-individual variability exists in the distribution of DHFR variants, and they influence MTX treatment outcome. To the best of our knowledge, there are no genetic studies reported from India, which have explored the influence of DHFR variants on the outcome of MTX treatment. Therefore, we aim to study the influence of DHFR rs408626 (-317A>G) and rs442767 (-680C>A) variants on ALL outcome in South Indian patients.

METHODS

A total of 70 ALL patients who were on MTX-based maintenance therapy were recruited for the study. DNA was extracted from leukocytes, and genotyping was done by real-time PCR.

RESULTS

The DHFR-317GG genotype was associated with the increased risk of relapse in patients with ALL (relative risk 2.25, 95% confidence interval (CI) 1.38 to 3.6, p = 0.02). DHFR-317AA and -680CA genotypes were found to be associated with severe leucopenia (p < 0.05). In Cox regression model, -317GG genotype was found to have lower relapse-free survival (hazard ratio (HR) 2.56, 95% CI 1.06 to 6.19, p = 0.03) and overall survival (HR 3.72, 95% CI 1.44 to 9.65, p = 0.007). Similarly, patients with white blood cell (WBC) count >50,000 cells/mm(3) were also found to have lower relapse-free survival (HR 2.20, 95% CI 1.10 to 4.79, p = 0.04) and overall survival (HR 3.30, 95% CI 1.45 to 7.53, p = 0.004).

CONCLUSION

The GG genotype of DHFR-317A>G variant is associated with increased risk of ALL relapse and lower overall survival in South Indian population. Both variants of DHFR (-317 AA and -680 CA) are found to be associated with severe leucopenia caused by MTX.

Outcome of B-Cell Acute Lymphoblastic Leukemia in Brazilian Children: Immunophenotypical, Hematological, and Clinical Evaluation

The aim of this study is to investigate the clinical, hematological, and immunophenotypic characteristics of Brazilian children with B-cell acute lymphoblastic leukemia (B-ALL) to identify prognostic biomarkers of the disease. Thirty-three children newly diagnosed with B-ALL were followed between March 2004 and December 2009. Information about the demographic profile, diagnosis, immunophenotype, clinical manifestations, and disease outcome were gathered from the patients' medical records. Of the 33 patients with B-ALL, 18 were male and 15 female. Eighteen patients were classified as high risk; 13 as low risk, and 2 as true low risk. The frequencies of cluster of differentiation (CD)10, CD19, and CD20 antigens were 69.7%, 81.8%, and 18.2%, respectively. Six patients (18.2%) had aberrant expression of myeloid antigens. At diagnosis, patients immunopositive for CD20 had elevated white blood cell counts (P = 0.018) and lower platelet counts (P = 0.017). The 6-year overall survival was 67.5%± 3.47%. Our results demonstrate the distinct immunophenotypic and prognostic characteristics of patients with B-ALL, which can be related to the Brazilian racial admixture. Consequently, these results will most likely aid in the selection of additional prognostic markers and their use in monitoring the clinical manifestations and treatment response among B-ALL patients.

Delayed diagnosis of leukemia and association with morbid-mortality in children in Pernambuco, Brazil

The objectives of this study were to describe the interval between symptom onset and diagnosis of acute leukemia, to assess risk factors for delayed diagnosis, and its effect on early morbid-mortality and event-free survival (EFS). Records of children aged 1 month to 18 years diagnosed with acute leukemia were reviewed for clinical, demographic, and health care provider factors, and for time to diagnosis. Of 288 patients diagnosed, 55% had a delay in diagnosis. The median time to diagnosis was 31 days. There were significant associations between the diagnostic delay and the distance from the tertiary care hospital (P=0.04), initial consultation in an outpatient clinic (P=0.04), presenting symptoms of bone/joint pain (P=0.04), family with more than 3 children (P=0.02), birth order of third or greater (P=0.009), paternal age <30 years (P=0.03), and paternal education <8 years (P=0.008). There was no association between delayed diagnosis and early morbid-mortality or EFS at 5 years. Initial consultation in an outpatient setting, presenting symptoms of bone/joint pain, and birth order of third or greater remained statistically significant in multivariate analyses, but the delay did not have an impact on early morbid-mortality or EFS. Education of primary care providers in atypical presentations of acute leukemia may decrease the diagnostic delay.

A sustainable model for pediatric oncology nursing education in low-income countries

Effectiveness of a nurse educator in the pediatric oncology unit in Guatemala was assessed by measuring completion of an education course, chemotherapy and central line competency, continuing education, and cost. All newly hired nurses completed the education course. Of the nurses employed, 86% participated in the chemotherapy course, and 93% achieved competency; 57% participated in the central line course, and 79% achieved competency. The nurses completed a mean of 26 hours continuing education yearly. The annual direct cost of the educator ($244/nurse) was markedly less than other models. This is an effective and sustainable means to educate nurses in low-income countries.

Pattern of relapse in childhood ALL: challenges and lessons from a uniform treatment protocol

This retrospective analysis of 254 children less than 15 years of age treated with MCP-841 protocol from June 1992 to June 2002 was undertaken to identify the pattern of relapse and determine management lacunae. Two hundred twenty-three (87.8%) children achieved a complete remission of whom 40 (17.9%) relapsed. The mean age of relapsed patients was 6.5 years. The male/female ratio was 9:1. There were 23 (57.5%) isolated bone marrow (BM), 7 (17.5%) isolated central nervous system (CNS), 2 (5%) isolated testicular, 5 (12.5%) BM+testes and 1 each of BM+CNS, CNS+testes, and isolated bone relapses. Twenty-seven children (67.5%) relapsed on-therapy whereas 13 (32.5%) relapsed posttherapy. All 9 CNS relapses occurred on-therapy whereas 5/8 (62.5%) of testicular relapses occurred posttherapy. Lymphadenopathy was the only significant predictor for relapse. High-risk features such as age less than 1 year and greater than 10 years (P=0.047) and white cell count greater than 50.0 x 10(9)/L (P=0.044) were significantly more frequent in patients with early on-therapy relapse than in patients with off-therapy relapse. The overall survival in the entire study cohort was 67+/-3.5%. Modest survival outcome, relapse while on chemotherapy and the higher incidence of CNS and testicular relapse indicate the need for reappraisal of our treatment protocol. There is a need of identifying risk factors and high-risk groups in our set of patients and risk-stratified intensification of chemotherapy in them.

UK-based real-time lymphoproliferative disorder diagnostic service to improve the management of patients in Ghana

The objective of the study was to evaluate the feasibility of a UK-based real-time service to improve the diagnosis and management of lymphoproliferative disorders (LPDs) in Ghana. Adult patients reporting to hospital with a suspected LPD, during a 1 year period, were prospectively enrolled. Bone marrow and/or lymph node biopsies were posted to the Haematology Malignancy Diagnostic Service (HMDS), Leeds, UK and underwent morphological analysis and immunophenotyping. Results were returned by e-mail. The initial diagnoses made in Ghana were compared with the final HMDS diagnoses to assess the contribution of the HMDS diagnosis to management decisions. The study was conducted at the two teaching hospitals in Ghana—Komfo Anokye, Kumasi and Korle Bu, Accra. Participants comprised 150 adult patients (≥12 years old), 79 women, median age 46 years. Bone marrow and lymph node biopsy samples from all adults presenting with features suggestive of a LPD, at the two teaching hospitals in Ghana, over 1 year were posted to a UK LPD diagnostic centre, where immunophenotyping was performed by immunohistochemistry. Molecular analysis was performed where indicated. Diagnostic classifications were made according to international criteria. Final diagnosis was compared to the initial Ghanaian diagnosis to evaluate discrepancies; implications for alterations in treatment decisions were evaluated. Median time between taking samples and receiving e-mail results in Ghana was 15 days. Concordance between initial and final diagnoses was 32% (48 of 150). The HMDS diagnosis would have changed management in 31% (46 of 150) of patients. It is feasible to provide a UK-based service for LPD diagnosis in Africa using postal services and e-mail. This study confirmed findings from wealthy countries that a specialised haematopathology service can improve LPD diagnosis. This model of Ghana–UK collaboration provides a platform on which to build local capacity to operate an international quality diagnostic service for LPDs.

Treatment strategies and regimens of graduated intensity for childhood acute lymphoblastic leukemia in low-income countries: A proposal

Cure rates for children with acute lymphoblastic leukemia (ALL) are 80-85% in high-income countries (HICs) in North America and Western Europe. However, cure rates are much lower in many low-income countries (LICs), where most cases of ALL occur. Over the past several decades partnerships ("twinning") between HIC and LIC pediatric oncology programs have led to major improvements in outcome for children with ALL in some LICs, often by developing time and resource intensive relationships that allow LIC centers to treat children with regimens similar or identical to those used in HICs. However, the resources are not available in most LICs to allow immediate introduction of intensive ALL treatment regimens similar to those used in HICs. With these thoughts in mind, we present a proposal for a systematic and graduated approach to ALL diagnosis, risk classification, and treatment in LICs. We have based the strategy and the proposed regimens on those developed by the Children's Cancer Group (CCG) and Children's Oncology Group (COG) over the past several decades, beginning with a first level regimen similar to CCG therapy of the early 1980s and then layering on successive treatment intensifications proven effective in randomized clinical trials. Simple monitoring rules are included to help centers decide when they are ready to add new treatment components. This proposal provides a framework that LIC centers can use to provide effective ALL therapy, particularly in regions of the world where few children are currently being cured.

Developing anticancer chemotherapy services in a developing country: Hodgkin lymphoma experience

BACKGROUND AND OBJECTIVE

Reporting on how the cancer treatment facilities were developed at a medical college hospital in India and the profile and outcome of patients with Hodgkin lymphoma (HL) at this new center were the objectives of the study.

METHODS

Patients under 18 years with a diagnosis of HL were evaluated using abdominal ultrasonography, CT scan examination of chest, abdomen and pelvis and bone marrow examination. Most patients were treated with combination chemotherapy. Departments of Radiodiagnosis and Pathology were involved for evaluation. Radiotherapy when required was made available at a nearby hospital.

RESULTS

Thirty-five patients between 1.2 and 18 years (median age 7 years) were diagnosed as HL during the study period. Advanced disease (Stage IIb or more) was present in 83% cases. Mixed cellularity was the commonest histological subtype (50.5%). Primary therapy used was COPP in 29 (83%) cases. Of the 34 patients who received treatment 30 showed initial good response to therapy. One patient responded to ABVD after having progression on COPP. Of 31 responders, 4 relapsed. Twenty-seven patients (80%) are surviving free of disease for a median follow up of 4.5 years (range 1.5-18 years). Chemotherapy was well tolerated. Febrile neutropenia occurred in four cases.

CONCLUSIONS

Pediatric HL in India was characterized by advanced disease at presentation. Mixed-cellularity was the predominant histological subtype. An effective program was developed with initial attention to patients with HL.

Status of minimal residual disease testing in childhood haematological malignancies

In children with acute leukaemia, measurements of minimal residual disease (MRD) provide unique information on treatment response and have become a crucial component of contemporary treatment protocols. In acute lymphoblastic leukaemia (ALL), the most useful MRD assays are based on polymerase chain reaction (PCR) amplification of antigen-receptor genes, and on flow cytometric detection of abnormal immunophenotypes. The latter is the only MRD assay available for most patients with acute myeloid leukaemia (AML). PCR amplification of chromosomal breakpoints and fusion transcripts can also be used to track MRD in a minority of patients with ALL or AML. Because of the strong correlation between MRD levels and risk of relapse, several ongoing regimens include treatment intensification for children with higher MRD. Treatment de-intensification for patients with early MRD clearance is also being tested. In addition to their direct clinical application, MRD measurements can be used to better understand the molecular and cellular mechanisms of drug resistance in vivo. The identification of new markers of leukaemia and the use of increasingly sophisticated technologies for detection of rare cells should further facilitate routine monitoring of MRD and elucidate the features of drug-resistant leukaemic cells.

Impact of childhood cancer on parental employment and sources of income: a Canadian pilot study

BACKGROUND

Loss of income and out of pocket expenses related to childhood cancer care can account for over 25% of a family's total disposable income, adding to the stress of facing a life-threatening disease. The objective of this pilot study was to assess the impact of childhood cancer on employment and sources of income within families.

PROCEDURE

A retrospective postal-administered questionnaire was used to collect information from parents of children diagnosed with cancer before 20 years of age between 1990 and 1996 in the province of British Columbia (n = 111).

RESULTS

Among full or part-time employed parents, 64% of mothers and 16% of fathers left their job after their child's diagnosis. The large majority of parents who left their jobs were away for less than 1 year (65% of mothers; 78% of fathers) and nearly all were able to return to the same job if they chose to do so (80% of mothers; 89% of fathers). Parents with children <10 years of age at diagnosis and those with leukemia were most likely to take leave from their jobs. There was considerable change in sources of income between the time of diagnosis and survey with more families relying on employment insurance, social assistance or other financial support at diagnosis. Reliance on sources of income other than salary decreased with time since diagnosis.

CONCLUSIONS

It appears that the diagnosis of childhood cancer may cause an important but short-term impact on the employment and income sources of affected families.

Development of a telemedicine model for emerging countries: a case study on pediatric oncology in Brazil

This article discusses a telemedicine model for emerging countries, through the description of ONCONET, a telemedicine initiative applied to pediatric oncology in Brazil. The ONCONET core technology is a Web-based system that offers health information and other services specialized in childhood cancer such as electronic medical records and cooperative protocols for complex treatments. All Web-based services are supported by the use of high performance computing infrastructure based on clusters of commodity computers. The system was fully implemented on an open-source and free-software approach. Aspects of modeling, implementation and integration are covered. A model, both technologically and economically viable, was created through the research and development of in-house solutions adapted to the emerging countries reality and with focus on scalability both in the total number of patients and in the national infrastructure.

Trends in childhood leukemia mortality in Brazil and correlation with social inequalities

BACKGROUND

Mortality from childhood leukemia has declined substantially in developed countries but less markedly in the developing world. This study was designed to describe mortality trends in childhood leukemia and the impact of social inequalities on these trends in Brazil from 1980 to 2002.

METHODS

Cancer mortality data by cause and estimates of resident population stratified by age and sex were obtained from the Brazilian Mortality Information System (SIM) for the years 1980 to 2002. Age-standardized (ages 0-19 years) mortality rates were calculated by the direct method using the 1960 world standard population. Trends were modeled using linear regression with 3-year moving average rates as the dependent variable and with the midpoint of the calendar year interval (1991) as the independent variable. The Index of Social Exclusion was used to classify the 27 Brazilian states. Pearson correlation was used to describe the correlation between social exclusion and variations in mortality in each state.

RESULTS

Age-standardized mortality rates for boys decreased from 2.05 per 100,000 habitants in 1984 to 1.44 100,000 habitants in 1995, whereas the observed corresponding decline among girls was from 1.60 per 100,000 habitants in 1986 to 1.14 per 100,000 habitants in 1995. Statistically significant declining trends in mortality rates were observed for boys (adjusted correlation coefficient [r(2)] = 0.68; P < .001) and girls (adjusted r(2) = 0.62; P < .001). Significant negative correlations between social inequality and changes in mortality were noted for boys (r = -0.66; P = .001) and for girls (r = -0.78; P < .001).

CONCLUSIONS

A consistent decrease in mortality rates from childhood leukemia was noted in Brazil. Higher decreases in mortality were observed in more developed states, possibly reflecting better health care.

Protocol-based treatment for children with cancer in low income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)--part II

Pediatric cancer programs in low-income countries (LIC) can improve outcomes. However, treatment must be tailored to the patient's living conditions and the availability of supportive care. In some cases, a more intense regimen will decrease survival since the increase in death from toxicity may exceed any decrease in relapse. Attempts to practice evidence-based pediatric oncology are thwarted by the lack of evidence derived from local experience in LIC to determine optimal therapy. This report summarizes treatment regimens used by pediatric oncologists from 15 countries of the Caribbean, Central and South America who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with hepatoblastoma, Wilms tumor, and histiocytosis treated on unmodified published protocols had outcomes comparable to those in high-income countries (HIC). Those with rhabdomyosarcoma, osteosarcoma, Hodgkin lymphoma, and acute myeloid leukemia treated with unmodified regimens had event-free survival estimates 10%-20% lower than those reported in HIC due to higher rates of toxic death, abandonment of therapy, and relapse. Treatment of retinoblastoma is complicated by advanced stages and extraocular disease at diagnosis; improved outcomes depend on education of pediatricians and the public to recognize early signs of this disease. Use of unmodified protocols for Burkitt lymphoma and acute lymphoblastic leukemia have been associated with unacceptable toxicity in LIC, so MISPHO centers have modified published regimens by giving lower doses of methotrexate and reducing use of anthracyclines. Despite the use of all-trans-retinoic acid during induction for acute promyelocytic leukemia, the incidence of fatal hemorrhage remains unacceptably high.

A simplified flow cytometric assay identifies children with acute lymphoblastic leukemia who have a superior clinical outcome

Bone marrow normal lymphoid progenitors (CD19+, CD10+, and/or CD34+) are exquisitely sensitive to corticosteroids and other antileukemic drugs. We hypothesized that, in patients with B-lineage acute lymphoblastic leukemia (ALL), cells with this phenotype detected early in treatment should be leukemic rather than normal. We therefore developed a simple and inexpensive flow cytometric assay for such cells and prospectively applied it to bone marrow samples collected on day 19 from 380 children with B-lineage ALL. In 211 patients (55.5%), these cells represented 0.01% or more of the mononuclear cells; results correlated remarkably well with those of more complex flow cytometric and molecular minimal residual disease (MRD) evaluations. Among 84 uniformly treated children, the 10-year incidence of relapse or remission failure was 28.8% +/- 7.1% (SE) for the 42 patients with 0.01% or more leukemic cells on day 19 detected by the simplified assay versus 4.8% +/- 3.3% for the 42 patients with lower levels (P = .003). These assay results were the strongest predictor of outcome, even after adjustment for competing clinicobiologic variables. Thus, this new assay would enable most treatment centers to identify a high proportion of children with ALL who have an excellent early treatment response and a high likelihood of cure.

International Collaboration on Childhood Leukemia

The current cure rate of childhood acute lymphoblastic leukemia has reached 80% in many industrialized countries, but in developing countries the rate is often less than 10%. To advance the cure rate, investigators have formed several parallel initiatives in both industrialized and developing countries through international collaboration and partnership. Among industrialized countries, investigators have combined data to conduct in-depth studies of the biology and heterogeneity of high-risk or drug-resistant subgroups of leukemia to identify optimal or novel treatments. Alliances have been established among government, local nongovernmental organizations, health care providers, and international groups to improve the survival rate of childhood leukemia in developing countries. "Twinning" partnerships between a well-established individual institution or study group and a pediatric cancer unit in a developing country has proved to be the most successful strategy to date.

Outcome of childhood acute lymphoblastic leukaemia in resource-poor countries

The causes of treatment failure in childhood acute lymphoblastic leukaemia are thought to differ between resource-rich and resource-poor countries. We assessed the records of 168 patients treated for this disease in Honduras. Abandonment of treatment (n=38), the main cause of failure, was associated with prolonged travel time to the treatment facility (2-5 h: hazard ratio 3.1, 95% CI 1.2-8.1 vs >5 h: 3.7, 1.3-10.9) and age younger than 4.5 years (2.6, 1.1-6.3). 35 patients died of treatment-related effects. Outcome could be substantially improved by interventions that help to prevent abandonment of therapy (such as funding for transport, satellite clinics, and support groups), and by prompt treatment of infection.