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ABSTRACT: BACKGROUND: Outcomes for relapsed childhood acute lymphoblastic leukemia (ALL) have not been documented in resource-limited settings. This study examined survival after relapse for children with ALL in Central America. METHODS: A retrospective cohort study was performed and included children with first relapse of ALL in Guatemala, Honduras, or El Salvador between 1990 and 2011. Predictors of subsequent event-free survival (EFS) and overall survival (OS) were examined. RESULTS: There were 755 children identified with relapsed disease. The median time from diagnosis to relapse was 1.7 years (interquartile range, 0.8-3.1 years). Most relapses occurred during (53.9%) or following (24.9%) maintenance chemotherapy, and the majority occurred in the bone marrow (63.1%). Following the initial relapse, subsequent 3-year EFS (± standard error) and OS were 22.0% ± 1.7%, and 28.2% ± 1.9%, respectively. In multivariable analysis, worse postrelapse survival was associated with age ≥ 10 years, white blood cell count ≥ 50 × 10(9) /L, and positive central nervous system status at the original ALL diagnosis, relapse that was not isolated central nervous system or testicular, and relapse < 36 months following diagnosis. Site and time to relapse were used to identify a favorable risk group whose 3-year EFS and OS were 50.0% ± 8.9% and 68.0% ± 8.1%, respectively. CONCLUSIONS: Prognosis after relapsed ALL in Central America is poor, but a substantial number of those with favorable risk features have prolonged survival, despite lack of access to stem cell transplantation. Stratification by risk factors can guide therapeutic decision-making. Cancer 2012. © 2012 American Cancer Society.
Cancer 11/2012; · 4.77 Impact Factor
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ABSTRACT: Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality.
This prospective cohort study included children aged 0-16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented.
Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0-20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0-3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09-8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03-1.81; P = 0.031) and in families with an annual household income <US$2,000 (OR 13.90, 95% CI 1.62-119.10; P = 0.016).
Illiteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.
PLoS ONE 01/2012; 7(8):e43639. · 4.09 Impact Factor
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ABSTRACT: Uneven strides in research and care have led to discrepancies in childhood cancer outcomes between high and low income countries (LICs). Collaborative research may help improve outcomes in LICs by generating knowledge for local scientific communities, augmenting knowledge translation, and fostering context-specific evaluation of treatment protocols. However, the risks of such research have received little attention. This paper investigates the relationship between pediatric oncology research in LICs and four core issues in the ethics literature: standard of care, trial benefits, ethics review, and informed consent. Our aims are to highlight the importance of this field and the need for further inquiry.
Pediatric Blood & Cancer 12/2011; 58(4):492-7. · 1.89 Impact Factor
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ABSTRACT: Most children with cancer live in low-income countries (LICs) where risk factors in paediatric acute lymphoblastic leukaemia (ALL) developed in high-income countries may not apply.
We describe predictors of survival for children in El Salvador with ALL. We included patients <16 years diagnosed with ALL between January 2001 and July 2007 treated with the El Salvador-Guatemala-Honduras II protocol. Demographic, disease-related, socioeconomic and nutritional variables were examined as potential predictors of event-free survival (EFS) and overall survival (OS).
260/443 patients (58.7%) were classified as standard risk. Standard- and high-risk 5-year EFS were 56.3 ± 4.5% and 48.6 ± 5.5%; 5-year OS were 77.7 ± 3.8% and 61.9 ± 5.8%, respectively. Among standard-risk children, socioeconomic variables such as higher monthly income (hazard ratio [HR] per $100 = 0.84 [95% confidence interval (CI) 0.70-0.99; P=0.04]) and parental secondary education (HR = 0.49, 95% CI 0.29-0.84; P = 0.01) were associated with better EFS. Among high-risk children, higher initial white blood cell (HR per 10×10(9)/L = 1.03, 95% CI 1.02-1.05; P<0.001) predicted worse EFS; socioeconomic variables were not predictive. The difference in EFS and OS appeared related to overestimating OS secondary to poor follow-up after abandonment/relapse.
Socioeconomic variables predicted worse EFS in standard-risk children while disease-related variables were predictive in high-risk patients. Further studies should delineate pathways through which socioeconomic status affects EFS in order to design effective interventions. EFS should be the primary outcome in LIC studies.
European journal of cancer (Oxford, England: 1990) 12/2010; 46(18):3280-6. · 4.12 Impact Factor
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ABSTRACT: We report on two very similar cases of vaginal embryonal RMS, botryoid variant, that relapsed 9 and 10 years after initial diagnosis, a few months after the menarche in both cases. A possible causal association with estrogen hormones is hypothesized, particularly for the second case described, in which estrogen receptors were negative in the primary tumor specimen and positive in the relapsing tumor specimen.
Pediatric Blood & Cancer 08/2008; 51(1):140-1. · 1.89 Impact Factor
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ABSTRACT: Managing older adolescents and young adults with cancer is a challenge, both medically and psychosocially: it is important to assess these patients' psychological issues and the type of services they need when deciding who should treat these patients, and where.
This study describes the pattern of psychological referral and consultation for older adolescents and young adults with cancer being treated at a pediatric oncology unit, as compared with the case of younger patients.
Between 1999 and 2006, 318 patients <15 (32% of the patients in this age group) and 117 >/= 15 years old (30%) were referred for psychological consultation. The number of interviews per patient was 2.8 for patients under fifteen and 7.8 for older patients. Younger patients were referred by all members of staff, while most older patients were referred by doctors, mainly because they had trouble adapting to the cancer's diagnosis and treatment. An ongoing, weekly, long-term psychotherapy was needed for 1% of patients <15 and 10% of those >/=15 years old.
Adolescents and young adults with cancer have specific psychological needs. While awaiting the full development of programs dedicated to these patients, they would seem to benefit from being treated in a multidisciplinary setting of the kind usually developed at pediatric units, fully integrating the psychological operators with the other staff members.
Pediatric Blood & Cancer 07/2008; 51(1):105-9. · 1.89 Impact Factor
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ABSTRACT: We report the case of a 15-year-old girl with a large gluteal and perineal rhabdomyosarcoma diagnosed at 24 weeks of pregnancy, whose management posed a great clinical dilemma for us. The patient refused to consider a therapeutic abortion, so we opted for a customized treatment with mild doses of chemotherapy administered weekly to control tumor growth while minimizing fetal and perinatal complications. After the delivery of a healthy female, we adopted a more intensive chemotherapy regimen plus irradiation. Despite an initially good response, the disease unfortunately progressed and the patient died of her disease.
Tumori 94(3):431-3. · 0.86 Impact Factor
