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Abstract
Background: Acute lymphoblastic leukemia (ALL) outcomes in adults remain inferior to those in children, prompting the use of pediatric-inspired protocols in older populations. However, evidence of their efficacy and toxicity in low- and middle-income countries (LMICs) is limited. This study compared the outcomes of childhood versus adult therapeutic protocols for ALL in a tertiary care center in Pakistan.
Methods: A retrospective cohort of 152 patients with ALL was stratified into two groups: those treated with a pediatric-inspired regimen (Childhood protocol, n=78) and those treated with a conventional adult regimen (Adult protocol, n=74). Primary outcomes were changes in hematological and biochemical parameters. Secondary outcomes included hematologic response rates, early induction mortality, and treatment-related toxicities.
Results: The pediatric-inspired protocol was associated with a superior platelet response (34.6% vs. 18.9%, p=0.021) but also significantly higher grade 3/4 hepatotoxicity (21.8% vs. 6.8%, p=0.015). A non-significant trend towards lower early mortality was observed in the Childhood protocol group (7.7% vs. 16.2%, p=0.098). Multivariate analysis identified a high baseline white blood cell (WBC) count (>50 x 10⁹/L) as the only independent predictor of early mortality (aOR=2.88, 95% CI [1.01, 8.24], p=0.048). Subgroup analysis revealed a significant interaction (p=0.045), where the Childhood protocol was associated with lower mortality in patients with a WBC ≤50 x 10⁹/L.
Conclusions: In a resource-limited setting, pediatric-inspired regimens for ALL show promise for improved hematological response and potentially lower early mortality in standard-risk patients but are accompanied by significantly increased hepatotoxicity. Future strategies should focus on risk-adapted protocol selection and enhancing supportive care to manage treatment-related toxicity.