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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 645-646

Challenges in managing acute leukemia in India

Department of Medical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India

Date of Submission30-Jun-2020
Date of Decision05-Jul-2020
Date of Acceptance09-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Tapan Saikia
Prince Aly Khan Hospital, Mazgaon, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_226_20

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How to cite this article:
Saikia T. Challenges in managing acute leukemia in India. Cancer Res Stat Treat 2020;3:645-6

How to cite this URL:
Saikia T. Challenges in managing acute leukemia in India. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 17];3:645-6. Available from: https://www.crstonline.com/text.asp?2020/3/3/645/295554

How do we react when we are confronted with a Hobson's choice, especially when managing patients with acute leukemia in India? The courageous ones with a positive frame of mind always find a way. Often, the goal of treating cancers in resource-constrained settings is the improvement of the quality of life, as very intensive therapy cannot be provided to majority of the patients.[1],[2],[3] Given this scenario, two articles published by Pandey et al. in the journal, one on oral agents in patients with acute myeloid leukemia (AML) and the other on minimal residual disease (MRD) in B-cell acute lymphoblastic leukemia (ALL), are noteworthy. [4,5] At the outset, we appreciate the efforts of the young team and hope they will continue to work and publish in this area. An accompanying editorial looks at both papers, which is not an easy task.[6]

A retrospective analysis has several limitations. We will restrict our comments only to a few relevant ones and we hope that the young authors take this as constructive criticism. In the article regarding the management of patients with newly diagnosed AML with an oral combination of prednisolone, 6-mercaptopurine, and etoposide, the authors have mentioned about the cost of the chemotherapy drugs alone, but not the cost of supportive care.[4] Apparently, some of the patients were managed in private institutes at times. It is well known that supportive care contributes to a major portion of the total cost of management of AML;[7] someone pays, and this should be analyzed. In addition, a cost and cost–benefit analysis is a very complicated issue and needs insights from people involved in the field.[8] We presume that the patients required plenty of blood components and antimicrobials during the 3 months of therapy, after which the response assessment was done. Although the inclusion of corticosteroids in the treatment has somein vitro rationale, it could be deleterious as corticosteroids increase the risk of fungal infections significantly. Second, the complete remission rate of 45% at 1 year is remarkable, as is the 1 year overall survival reported by the authors;[9] I hope that the authors have included all 'intent to treat' patients. The authors have mentioned that all the patients were included; however, after treating thousands of AML patients, it is clear in our experience that several of these patients are not fit for any therapy. Upon censoring, the results look promising, but it becomes impossible to improve upon them in the subsequent studies. This is a self-created trap that young investigators fall into.

In the second study, the authors report on minimal/measurable residual disease (MRD) in a cohort of B-cell ALL.[5] At present, MRD is considered the most important prognostic factor in ALL. Equally important are the age, cytogenetics, and known molecular abnormalities.[10] The technology for detection of MRD in ALL is evolving rapidly; it includes multipanel immunophenotyping and polymerase chain reaction-based molecular techniques. Efforts are also focused on euroflow, a flow cytometry platform, to detect >5 log cell kill.[11] In this study, the authors outsourced the testing of the day-35 induction therapy marrow samples to an accredited laboratory. The authors could have divided the cohort according to age groups, such as 1–9 years and older. This would have further strengthened the results. In addition, we believe that the time has come to move beyond MCP-841 protocols. The cost of high dose cytarabine along with supportive care is not negligible. Perhaps high-dose methotrexate will cost the same, as the risk of infections following this agent is low. It is equally important to bring in other drugs incorporated in intermediate- and high-risk patients.

In conclusion, it is a pity that in Third World countries, we cannot use novel drugs that have begun to change the landscape of management of acute leukemia.[12],[13],[14]

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Kumar K, Radhakrishnan V, Dhanushkodi M, Kalaiyarasi JP, Mehra N, Kumar AR, et al. Oral etoposide and cyclophosphamide: A low-cost palliative metronomic chemotherapy in advanced pediatric cancers. Cancer Res Stat Treat 2020;3:64-8.  Back to cited text no. 2
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Pandey A, Deshpande P, Singh A, Singh S, Murari K, Aryan R. Oral prednisolone, etoposide, 6-mercaptopurine (PREM) metronomic chemotherapy in treatment naïve and partially treated acute myeloid leukemia in a resource constrained setting. Cancer Res Stat Treat 2020;3:172-82.  Back to cited text no. 4
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Pandey A, Ahlawat S, Singh A, Singh S, Murari K, Aryan R. Outcomes and impact of minimal residual disease (MRD) in pediatric, adolescent and young adults (AYA) with acute lymphoblastic leukemia treated with modified MCP 841 protocol. Cancer Res Stat Treat 2020;3:183-91.  Back to cited text no. 5
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Fung A, Horton S, Zabih V, Denburg A, Gupta S. Cost and cost-effectiveness of childhood cancer treatment in low-income and middle-income countries: A systematic review. BMJ Glob Health 2019;4:e001825.  Back to cited text no. 8
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Lustosa de Sousa DW, de Almeida Ferreira FV, Cavalcante Félix FH, de Oliveira Lopes MV. Acute lymphoblastic leukemia in children and adolescents: Prognostic factors and analysis of survival. Rev Bras Hematol Hemoter 2015;37:223-9.  Back to cited text no. 10
Theunissen P, Mejstrikova E, Sedek L, van der Sluijs-Gelling AJ, Gaipa G, Bartels M, et al. Standardized flow cytometry for highly sensitive MRD measurements in B-cell acute lymphoblastic leukemia. Blood 2017;129:347-57.  Back to cited text no. 11
Rowe JM, Tallman MS. How I treat acute myeloid leukemia. Blood 2010;116:3147-56.  Back to cited text no. 12
DiNardo CD, Wei AH. How I treat acute myeloid leukemia in the era of new drugs. Blood 2020;135:85-96.  Back to cited text no. 13
Rafei H, Kantarjian HM, Jabbour EJ. Recent advances in the treatment of acute lymphoblastic leukemia. Leuk Lymphoma 2019;60:2606-21.  Back to cited text no. 14


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