Implementation of a graduated-intensity approach for acute lymphoblastic leukemia in a Rwandan district hospital

Background: Acute lymphoblastic leukemia (ALL) outcomes in low-income countries (LICs) are poor, with only 20% to 50% of patients being successfully treated.1 Many of the treatment failures are the result of recurrent disease but treatment-related mortality (TRM) is also increased. Hunger et al2 have proposed graduated-intensity regimens for ALL in resource-limited settings so that capacity for managing toxicity can be built over time without excessive TRM.

The Butaro Cancer Center of Excellence (BCCOE) is based in a rural Rwandan district hospital and uses a task-shifted model of care. General practitioners, pediatricians, and internists provide care using nationally approved treatment protocols and receive remote technical support from cancer centers in the United States. Starting in 2012, BCCOE implemented the low-intensity Hunger 1 regimen to treat ALL patients. Once acceptable TRM was documented, we transitioned to a more intensive regimen, Hunger 2, which incorporates a delayed intensification phase

Aims: We aimed to assess the efficacy and safety of a graduated-intensity approach for patients receiving treatment for ALL at BCCOE in Rwanda beginning in October 2016.

Methods:
Inclusion criteria - Adult and pediatric patients with a pathology-confirmed diagnosis of ALL who were treated according to the Hunger framework from October 2012 to September 2017 and were included in our study.

Exclusion criteria - Any patient with ALL who received previous treatment with chemotherapy was excluded from the study cohort.

Study design - In this retrospective cohort, primary outcome variables were toxicity and efficacy of the Hunger 1 regimen and early outcomes for patients receiving the Hunger 2 regimen at the end of delayed intensification (24 weeks).

Acknowledgments: The authors thank the University of Global Health Equity and the Dana-Farber Cancer Institute and Boston Children’s Cancer and Blood Disorders Center for ongoing support and technical assistance throughout this research project.