Disparities in health systems models of leukemia survival in low-income countries

Paula Aristizabal, MD, MAS

Implementing health systems strengthening models appears to be effective in reducing leukemia survival disparities among patients in low- and middle-income countries, according to findings of a study to be presented at the annual meeting 2023 from the American Society of Clinical Oncology.

“Sustainable improvements in cancer outcomes in low- and middle-income countries are achievable with innovative cross-border programs, especially in shared borders between a high-income country and a low-income country,” Paula Aristizabal, MD, MAS , Associate Professor of Clinical Pediatrics, Division of Pediatric Hematology/Oncology, University of California, San Diego (UCSD), said in a presentation of the data ahead of the meeting.

As the global burden of childhood cancer increases, survival rates remain stagnant in low- and middle-income countries, compared to high-income countries, “creating this huge survival gap,” Aristizabal said, adding that leukemia acute lymphoblastic is the most common pediatric disease. cancer and is one of the leading causes of death among children in low- and middle-income countries.

Because of the significant health disparities that exist in the U.S. border region, she noted that because Children’s Hospital is located just 23 miles from Tijuana, UCSD partners with the public sector. of Baja California, Mexico, to improve outcomes in children with cancer across the border region.

Following this, UCSD partnered with St. Jude Children’s Research Hospital to establish a “twinning approach” in which a center of excellence in a high-income country collaborates and mentors a center in a low- and middle-income countries, particularly in this case, with a pediatric cancer centre.

“The goal is to improve the survival of children with cancer through the sharing of knowledge, technology and organizational skills; also consultation of clinical cases, teaching, research and training; and other health systems strengthening models because we are focused on capacity building and sustainability,” said Aristizabal, adding that for the program in Mexico, the focus was primarily on capacity building and the sustainability of Tijuana General Hospital.

As a result of this partnership, in 2013, the institutions implemented the WHO Framework for Action for Health Systems Strengthening (HSS) consisting of 6 building blocks: health service delivery, health workforce, systems health information, access to essential medicines, financing, leadership and governance.

“As the number of leukemia patients increases, we wanted to reduce this reliance on international collaborators here in the United States and ensure long-term sustainability,” Aristizabal said. “And the overall goal of implementing the WHO action framework into the already existing training curriculum was to improve survival for acute lymphoblastic leukemia, improve systems efficiency, provide rapid access to care and to ensure the protection and sustainability of social and financial risks over time.”

In the study, 109 children were treated at Tijuana General Hospital. The median age was 7 years old and just over 50% were female. Additionally, 36 patients had standard-risk disease and 73 had high-risk leukemia.

The pre-implementation phase was envisaged from 2008 to 2012, while the post-implementation phase was from 2013 to 2017.

The 5-year overall survival (OS) rate increased from 59% pre-implementation to 65% post-implementation, “and that was a significant improvement,” Aristizabal commented.

When stratified by risk, those who were at standard and high risk saw improved OS between the pre-implementation and post-implementation phases (73% to 100% and 48% to 55%, respectively).

“It’s really remarkable because the survival is the same as what we have here in San Diego for high-risk patients,” Aristizabal said. “Still, this is an area for improvement and we are working on additional strategies to help improve this survival for high-risk patients.”

The investigators demonstrated that the Global Action Framework model, with a focus on sustainability in particular, was effective in reducing leukemia survival disparities in Tijuana. “Geographical proximity, mentorship and data-driven projects to improve care led to better clinical outcomes, especially survival, which was our main goal.” concludes Aristizabal. “And the capacity building resulted in the implementation of disease-specific treatment guidelines and a highly trained team capable of providing high-quality supportive care.”


Aristizabal P, Rivera Gomez R, Correa Ribeiro R, Roberts W. Childhood Leukemia Survival at the US-Mexico Border: Creating Sustainable Leukemia Care Using Health Systems Strengthening Models. J Clin Oncol. 2023;41:16. Summary 1502

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