Using a Health Systems Strengthening Approach in the US-Mexico Border Region Improving Survival Rates of Children with ALL

By Jo Cavallo

Published: 05/26/2023 12:04:00

Last update: 05/26/2023 11:19:27

The implementation of a collaborative program between North American and Mexican medical institutions to obtain sustainable and high quality care in a public hospital in the border region between the United States and Mexico for children with leukemia acute lymphoblastic (ALL) disease and improving outcomes resulted in significant improvements in the 5-year overall survival of these patients. According to the study results, the 5-year overall survival rates of children with standard-risk and high-risk ALL increased from 52% to 82% and from 46% to 76%, respectively. The Aristizabal et al study will be presented at the 2023 ASCO Annual Meeting (abstract 1502).

Improvements over the past 5 decades in the treatment of children with ALL have resulted in cure rates approaching 90% in high-income countries. However, in low-resource settings, childhood ALL cure rates drop between 40% and 70% due to a multitude of factors, including health systems in these settings that are ill-equipped to manage cancer care for these patients.

In this study, Paula Aristizabal, MD, MAS, pediatric hematologist-oncologist at Rady Children’s Hospital in San Diego and associate professor of pediatrics in the division of pediatric hematology/oncology at UC San Diego Health, and her colleagues investigated how international collaborative strategies can improve outcomes for children with leukemia in low- and middle-income countries, especially those that share a border with high-income countries.

Study methodology

In 2013, in a partnership between North American and Mexican institutions, researchers used a model for health systems strengthening developed by the World Health Organization (WHO) called Framework for Action, which included areas in care delivery services, workforce, information systems, access to essential medicines, financing, leadership and governance – to implement a sustainable program with the aim of improving results of ALL at the General Hospital in Tijuana, Mexico.

Researchers assessed program sustainability indicators and prospectively assessed clinical characteristics, risk classification, and survival outcomes in 109 children with ALL in hospital from 2008 to 2012 (prior to program implementation). ) and from 2013 to 2017 (after implementation).

A cross-border collaborative program between institutions in Mexico and California improved the overall 5-year survival of children with standard-risk and high-risk ALL treated in Tijuana. Reductions in survival disparities in cancer outcomes are achievable with cross-border programs, especially shared borders between upper and lower middle income countries.

Principle results

The researchers’ approach led to a fully staffed leukemia ward at the hospital with sustainable training programs; evidence-based, data-driven projects to improve clinical outcomes; and funding for drugs, supplies and personnel through local partnerships.

They found that the 5-year overall survival before and after implementation of children with standard-risk and high-risk ALL improved from 52% to 82% and from 46% to 76%, respectively. All sustainability indicators improved significantly between 2013 and 2017.

“Using a health systems strengthening approach, we improved leukemia care and survival at a Mexican public hospital in the US-Mexico border region. The demonstrated increase in overall survival over a decade after the implementation of our program validates the use of health systems strengthening models, as they are not only effective in improving clinical outcomes, but also serve as [a] financial and organizational means to sustainably build capacity. Our model serves as an example for future international partnerships aimed at sustainably improving cancer outcomes in low- and middle-income countries. Future research should assess best practices in establishing global health collaborations with particular attention to the individual circumstances that impact the delivery of health care locally in each unique community,” the authors concluded. the study.

Clinical significance

In an ASCO press briefing detailing the results of this study, Dr Aristizabal said that using a combination of twinning – the partnership of a center of excellence in a high-income country with a center in a low- and middle-income country to share knowledge, technology and organizational skills – and the WHO Framework for Action model for sustainability has been effective in reducing leukemia survival disparities. “Sustained improvements in cancer outcomes in low- and middle-income countries are achievable through innovative cross-border programs, especially in shared borders between a high-income country and a low-income country,” said Dr Aristizabal .

“As I heard Princess Dina Mired of Jordan [President-Elect of the Union for International Cancer Control (UICC)] saying repeatedly, “Your zip code shouldn’t determine whether you survive cancer,” said press conference moderator Julie R. Gralow, MD, FACP, FASCO, chief medical officer and executive vice president of ASCO, commenting on Dr. Aristizabal’s findings. “And that’s an example of kids being so close and not having the same benefits. Your program was mostly about capacity building, but in previous discussions you also told us that because of this partnership that continued, you could get medicine from the Mexican Ministry of Health, which was not the norm across the country, so this partnership also involved the Mexican government in access to medicine, which I think is an important element.

“It takes a lot of partners – not just one village, but a lot of partners – to achieve these results,” Dr. Gralow concluded.

Disclosure: Funding for this study was provided by Rady Children’s Hospital San Diego, Patronato Foundation. For full disclosures from the study authors, visit

The content of this article has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the views and opinions of ASCO®.

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