Access Determines Outcomes for People with Acute Lymphoblastic Leukemia in Low- and Middle-Income Countries

Children who develop leukemia in low- and middle-income countries (LMICs) have a lower chance of long-term event-free survival than their counterparts in high-income countries (HICs). Causes of excess treatment failure in LMICs include lack of diagnosis, misdiagnosis, refusal and abandonment of treatment, toxic death and excess relapse. These barriers to cure of childhood cancer in LMICs are interdependent and cannot be resolved separately. While some proposed solutions require substantial funding, many inexpensive improvements can be made with existing resources. Lack of diagnosis can be addressed by publicizing early warning signs and encouraging immediate phone consultation or referral to specialist centers. Small investments in diagnostic capabilities like flow cytometry can decrease misdiagnosis. Universal health coverage that incorporates support for families in need can impact abandonment, especially when combined with psychosocial and logistical support from nongovernmental organizations. Locally adapted treatment protocols, infection control programs, and nurse training can reduce toxic death and thus increase survival rates. Finally, sustained and consistent access to high-quality chemotherapy that has been vetted by third parties can reduce relapse. Access to a pediatric unit that routinely conducts research to reduce treatment failure in each category underpins all interventions, since only through local research and continuous quality improvement based on local data using local resources can sustained progress be made. International collaboration for research, education, and technology sharing has proven to be extremely useful to overcome each cause of treatment failure, and universal access to research and care in the context of internationally networked pediatric oncology units benefits children everywhere.