Barriers to Care and Outcomes of Pediatric Acute Lymphoblastic Leukemia Treatment in the Gaza Strip

BACKGROUND

Childhood acute lymphoblastic leukemia (ALL) is the most common pediatric cancer worldwide. Although children in high-income countries enjoy survival rates of ~90%, children in countries with limited resources suffer from survival rates of <35%. No published data on pediatric cancer incidence, management, or outcomes in the Gaza Strip are available.

METHODS

A retrospective cohort study was undertaken for pediatric (below 12 y of age) ALL diagnoses admitted to the only pediatric cancer ward in the Gaza Strip between 2010 and 2015. Outcomes included event-free survival (EFS) and overall survival (OS) calculated by Kaplan-Meier estimates. Events were defined as induction failure, relapse, and death.

RESULTS

The 3-year EFS estimate was 80% (95% confidence interval [CI], 66%-89%). The EFS at 1 and 3 years for high-risk ALL was 55% (95% CI, 27%-76%) and 23% (95% CI, 4%-51%), respectively. The 3-year OS was 93% (95% CI, 82%-97%). The 3-year OS for high-risk ALL was 69% (95% CI, 30%-90%). All 84 (100%) patients required referral to an outside hospital for definitive ALL diagnoses and induction therapy. Forty-four (52%) patients required at least one additional referral.

CONCLUSIONS

The overall outcomes demonstrated relatively high survival rates at 3 years which may be artificially elevated due to exclusion of adolescents, limited follow up, and deceased patient charts unavailable. Structural determinants of health in Gaza lead to limited diagnostic and treatment capabilities, limited access to advanced medical training, and reliance on out-of-territory transfers for care. These barriers impact the access to comprehensive pediatric care within the Gaza Strip.

Unique Barriers to Care and Outcomes of Pediatric Acute Lymphoblastic Leukemia Treatment in Gaza City, Occupied Palestinian Territory

Abstract 56

Background:

Although cure rates for childhood acute lymphoblastic leukemia (ALL) in developed countries surpass 90%, 1 rates in resource-limited countries, to which barriers to care contribute, are as low as 35%. 2 In the Gaza Strip—a lower middle-income economy 3 —children face unique barriers to ALL treatment. We undertook this work to describe barriers to care for patients with pediatric ALL as well as treatment outcomes at the only pediatric oncology ward in the Gaza Strip.

Methods:

A comprehensive review of 131 charts was performed. Eighty-four patients met an inclusion criterion of diagnosis of ALL by bone marrow evaluation between 2010 and 2015 in children age < 12 years.

Results:

Eighty-four patients with ALL (T cell, 12 [14%]; pre-B cell, 72 [86%]) were stratified as being at standard (n = 64; 76%), intermediate (n = 3; 4%), or high risk (HR; n = 17; 20%). Of patients, 100% were referred to an international hospital for definitive diagnosis and induction therapy; 52% required at least one additional international hospital referral as a result of chemotherapy shortages (n = 8), methotrexate monitoring (n = 28), induction failure (n = 5), or relapse (n = 5). Three-year overall survival was 93% (CI, 82% to 97%), event free survival (EFS) was 80% (CI, 66% to 89%; events: death, induction failure, and relapse), and EFS of HR patients was 23% (CI, 4% to 51%).

Conclusion:

HR patients had extremely poor outcomes, even compared with those in other resource-limited settings. 4 Overall, patients experienced relatively high overall survival and EFS, which was likely confounded by exclusion of HR patients age > 12 years because of low pediatric age cutoff and missing charts. Barriers to care, including limited freedom of movement, contribute to delays in treatment, perhaps affecting outcomes of the HR cohort. An NGL–Ministry of Health partnership is addressing these barriers 5 by providing resources to decrease referrals.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.