Although acute lymphocytic leukemia (ALL) is relatively rare, it is the most common cancer diagnosed in children, representing approximately one-quarter of cancers diagnosed in those younger than 15 years.1 Physicians and researchers made incredible strides in treating ALL in children over the past few decades, with the introduction of intrathecal chemotherapy combinations and refinement in dosing and management of adverse events.
These developments transformed what was once considered a uniformly fatal cancer into one with a cure rate approaching 90 percent. However, these advances didn’t translate to many low- and middle-income countries, where the disease remained a death sentence for children.
Until recently, El Salvador was one such country. In 1990, more than 90 percent of children with ALL did not survive into adulthood. That was the grim prognosis facing the mother of a young Salvadoran boy who was diagnosed with ALL in 1990, shortly after his country had emerged from a civil war. The mother, seeing no viable options for treatment in El Salvador, decided to seek treatment in the U.S., recounted Raul C. Ribeiro, MD, a member of the oncology department at St. Jude Children’s Research Hospital in Memphis. She flew with her child to Tennessee for treatment at St. Jude, but unfortunately he died shortly thereafter.
Upon returning to El Salvador, the mother was determined to bring medical expertise found in the U.S. and other high-income countries back to the children in her own country, so that they could consistently receive efficient diagnoses and quality treatment.
She founded the Fundación Ayúdame a Vivir (Help Me to Live Foundation) in 1991 in memory of her son. For two years, the foundation raised money on its own. Then, in 1993, the mother delivered an impassioned plea for help to representatives from St. Jude; the hospital obliged.
Since 1997, Dr. Ribeiro has served as director of the hospital’s International Outreach program – an initiative to share knowledge, technology, and organizational skills worldwide to help increase childhood cancer cure rates. During his tenure, Dr. Ribeiro has helped establish partnerships with 19 medical institutions in 14 countries.
These thriving collaborations have since become models for treating cancer in other low- and middle-income countries throughout the world: In 1993, the five-year survival rate for children with ALL in El Salvador was only 5 percent; in 2000, it climbed to nearly 50 percent.2
“With childhood leukemia, the single biggest predictor of whether you recover or not is where you happen to have been born,†Carlos Rodriguez-Galindo, MD, chairman of St. Jude’s global pediatric medicine department. told The New York Times.3 “We’re talking about many thousands of young children dying every single year of diseases that we have known how to cure for decades.â€
ASH Clinical News spoke with Dr. Ribeiro and Roberto Vasquez, MD, a pediatric oncologist at the Benjamin Bloom Hospital in El Salvador, about the challenges of implementing this program, the success it has generated, and where else such a program might flourish.
Lower Income, Higher Prevalence
ALL is the most expensive childhood cancer to treat. Recent estimates place the average cost of inpatient treatment between $191,082 and $216,439, which translated to daily costs ranging between $2,283 and $2,840.4
But it is estimated that 80 percent of children who are diagnosed with cancer live in low- and middle- income countries.5 There, it is rare for a child to have access to high-quality treatment, and those who do are often forced to abandon it due to high costs and long travel distances. Only one in five of these children will be cured.
According to Dr. Vasquez, in 1991, the Benjamin Bloom Hospital in San Salvador, El Salvador’s tertiary care hospital for children, had no pediatric oncologists or nurses on staff who were trained specifically to care for patients with leukemia. At the time, nearly half the country was in poverty – meaning that few of the children who received a timely diagnosis were able to pay for effective treatment. Rates of treatment-related mortality remained high compared with those among children in higher-income countries.
Treating pediatric ALL was not a priority when limited resources might go further in treating patients with simpler, more common diseases, Dr. Vasquez explained.
Beginning With Twinning
After the mother’s appeal, St. Jude agreed to support a program in El Salvador for one year. The group conducted a site visit and developed a plan to deliver high-quality treatment for pediatric ALL at the Benjamin Bloom Hospital.