Wednesday, 9 June 2010

What is the outcome of children with Acute Lymphocytic Leukemia (ALL) in India?

The answer to this question, depends on whose asking it and to what purpose.

At an individual level (when access to treatment is not a barrier), currently the standard 5-year survival in most of the developed world is 80-90% with that for low-risk ALL even higher than 90%. The best published results from India are 59% 5-year survival for children with ALL treated from 1985 to 2003 in CMC Vellore (Bajel et al, 2008), and of 57% in those treated from 1990 to 1993 in Tata Memorial Hospital, Mumbai (Advani et al, 1999). For low-risk ALL, these survival figures are around 73-77%. It is important to point out, that these results from India are calculated after censoring (removing) those children with ALL who refused to start treatment or abandoned ongoing active treatment. There are some unpublished data suggesting better outcomes - 70% 4-year survival of children with ALL treated at Sir Ganga Ram Hospital in Delhi (Sachdeva et al, SIOP 2007); and 94% survival after median follow-up of two years of children with ALL treated at Apollo Hospital in Delhi (Mahajan et al, SIOP 2008).

A more accurate reflection of outcomes of children with ALL in India can be obtained when we include all those who refused and abandoned treatment and then calculate the survival. This is particularly relevant to clinicians, epidemiologists and health planners. To my knowledge, the recent paper from PGI in Chandigarh is the only one to publish such data. It shows a 4-year overall survival of 33% and a 10-year overall survival of 30% for children with ALL diagnosed at that institute from 1990 to 2006 (Kulkarni et al, 2009). Other sources of such information are the population-based cancer registries. Only two reports have ever been published looking at population-based 5-year survival in children with cancer and these were 35% from Bangalore for the period 1982 to 1987 (Nandakumar et al, 1996); and 39% for Chennai for the period 1990 to 2001 (Swaminathan et al, 2008).

In a nutshell, 6 out of 10 children with ALL in India will have long term survival (and cure) if they are compliant with their treatment. If treatment uptake and compliance is variable, only 1 out of 3 children in such settings would be cured. These outcomes apply only to those treated in specialist tertiary centres in urban areas. For those in rural areas or non-specialist centres, the outlook is certain to be worse.

Saturday, 5 June 2010

Childhood Cancer Survival in Philippines (and India) lags by >30 years than in Developed Countries

Survival of childhood cancer has enormously improved in the developed world with current 5-year survival for leukemia and lymphoma now around 80% and 90% respectively. An interesting recent paper shows that for the period 2001-2005 the 5-year survival of children with these cancers in Philippines is much lower (32.9% for leukemias and 47.7% for lymphomas) (Redaniel et al, Br J Cancer, 2010). These figures are even less than the survival seen in USA during 1976-1980 (57.7% for leukemias and 60.9% for lymphomas). These observations although not unexpected, do highlight the enormous gap in the outlook of children with cancer in the developing world.

What about India? There is limited population-based childhood cancer survival data. The most recent data from Madras Metropolitan Tumour Registry shows that for the period 1990-2001 the 5-year survival of children with leukemias in Chennai was 36.3% and lymphomas was 55.3% respectively (Swaminathan et al, Int J Cancer, June 2008). In this study, a combination of completeness of treatment and type of hospital emerged as significant prognostic factors for survival.