Global socioeconomic disparities in ALL: treatment challenges in Brazil and Guatemala

This series of podcasts covers global socioeconomic disparity in ALL. In this episode, the ALL Hub asked Eduardo Chapchap, Hospital Israelita Albert Einstein, São Paulo, BR and Federico Antillion, Unidad Nacional de Oncologia Pediatrica, Guatemala City, GT about the treatment challenges in ALL, including:

• Do treatment outcomes differ among race and ethnicity? Why do you think this is?
• What are the obstacles to treatment adherence?
• How do you sequence treatment in relapsed/refractory (R/R) B-ALL?

Chapchap and Antillion discussed socioeconomic disparities in ALL across high middle-income countries (HMIC), low middle-income countries (LMIC), and within adult and pediatric populations.

Chapchap highlighted that treatment adherence is more of a challenge in childhood versus adult ALL. Factors impacting adherence include concern among patients about the short and long-term adverse effects of treatment. Additionally, some patients misunderstand the importance of treatment adherence, and thus communication should be increased between patients and their physicians. Psychological issues amongst adolescent patients in particular can affect adherence to treatment. Social and economic barriers, such as distance from the centers and familial issues, can also cause low adherence to treatment.

Antillion mentioned the educational level of the family and language barriers as the main obstacles to treatment adherence. Treatment adherence remains particularly challenging in the adolescent population.

Across the public systems in Brazil, there is currently no access to immunotherapies for R/R B-cell ALL, though blinatumomab could be approved for early marrow relapses for children in the near future. In the private settings, there is access to blinatumomab, inotuzumab ogamacin (InO), and CD19-directed chimeric antigen receptors (CAR) T-cell therapies. Important factors in deciding the sequencing of immunotherapies include tumor burden, timing of relapse, CD19/CD20 expression, and prior regimens.

For patients who are minimal residual disease-positive with bone marrow relapses, blinatumomab could be an ideal option. For those with high tumor burden with early and/or primary refractory disease, InO would be a suitable option followed by blinatumomab or stem cell transplantation consolidation. For late relapse, cytoreductive therapy with pediatric-inspired regimens followed by blinatumomab consolidation could be an option. CAR T-cell therapies are generally reserved for post stem cell transplantation.

In Guatemala, sequencing of treatment depends on the timing of relapse, tumor burden, and whether there are new or different translocations. For standard or intermediate-risk patients with late relapse conventional chemotherapy is given. High-risk patients with early relapse are directed to other treatment options outside of Guatemala, as there is currently no access to blinatumomab, InO or CAR T-cell therapy, and in some cases patients will receive palliative and supportive care.