title: Improving outcome of acute lymphoblastic leukemia with a simplified protocol: report from a tertiary care center in north India.
abstract: The outcome of malignancies in low- and middle-income countries (LMICs) is hampered owing to numerous factors. Current protocols are complex, demanding supportive care, often not optimally available. We de-escalated the UKALL 2003 protocol to improve the outcome of acute lymphoblastic leukemia (ALL) at our center.
  
  
  
  In 2007-2009, children were treated as per the UKALL 2003 protocol (protocol 1). In 2010 and 2011, a modified version of the UKALL 2003 (protocol 2) was followed.
  
  
  
  Three hundred and seventy-four children aged 5.71+3.1 (1-13) years were treated. Remission was achieved in 335 of the 338 who completed induction. Treatment-related mortality decreased significantly with the modified protocol (P ≤ 0.001). Relapses were similar with both protocols. Protocol used, regimen, counts at diagnosis, weight for age, gender, education of parents and occupation of caregiver were associated with the outcome of death (P < 0.05). On Cox proportional hazard analysis, patients on protocol 1, female gender and weight ≤5th centile had a greater hazard of dying (0.46 [P < 0.0001]; 1.5 [P = 0.04] and 1.64 [P = 0.01]). The 3 years overall survival (OS) with protocols 1 and 2 was 54.8% (95% CI 47.4-61.7%) and 73.9% (95% CI 66-79%) (P < 0.001), respectively. The event-free survival with protocols 1 and 2 was 50.8% (95% CI 43-57%) and 65.7% (95% CI 58-72%) (P < 0.001), respectively.
  
  
  
  A steady improvement in survival has been observed at our center to a 3-year present OS of 73.9% with reduction in treatment intensity. The way forward for LMICs is to formulate rational treatment protocols at par with resources.
authors.affiliation: Pediatric Hematology Oncology Unit, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Amita
authors.initials: A
authors.lastname: Trehan
authors.affiliation: Pediatric Hematology Oncology Unit, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Bansal
authors.affiliation: Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Neelam
authors.initials: N
authors.lastname: Varma
authors.affiliation: Department of Pediatric Hematology, Sheffield Children's Hospital, Sheffield, United Kingdom.
authors.forename: Ajay
authors.initials: A
authors.lastname: Vora
mesh_terms: D000293:Adolescent; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001215:Asparaginase / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D003907:Dexamethasone / Q000008:administration & dosage; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007194:India; D007223:Infant; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy* / Q000473:pathology; D009367:Neoplasm Staging; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy* / Q000473:pathology; D011379:Prognosis; D012074:Remission Induction; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D062606:Tertiary Care Centers; D014750:Vincristine / Q000008:administration & dosage
chemical_list: D014750:Vincristine; D003907:Dexamethasone; D001215:Asparaginase
keywords: acute lymphoblastic leukemia; mortality; protocol; survival