Data from Pakistan suggest that pediatric patients with acute lymphoblastic leukemia (ALL) living in low- or middle-income countries (LMICs) are likely to have lower overall survival (OS) and disease-free survival rates than patients living in developed countries, according to research published in JCO Global Oncology. These findings are primarily due to high white blood cell (WBC) counts, malnutrition, delayed presentation, previous steroids use, intensive chemotherapy, and poor response to the induction chemotherapy in the evaluated population, the authors found.

Population-level data suggest that as many as 80% of pediatric patients with cancer live in LMICs, and data are needed about their outcomes with hematological and solid neoplasms. For this prospective cohort study, researchers evaluated data between 2012 and 2021 to evaluate clinical characteristics, treatment outcomes, and prognostic factors among pediatric patients living in Pakistan diagnosed with ALL.

Overall, 945 patients were enrolled. In this cohort, 50.9% and 49.1% were categorized to standard-risk and high-risk groups, respectively; 63.2% of patients were male sex, the average age was 5.73 years, and the most common symptoms at clinical presentation were pallor (95.2%), fever (84.2%), and visceromegaly (83.2%). The mean WBC in the cohort, moreover, was 56.6 109/L.

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Analysis showed that neutropenic fever with consequent myopathy was the most frequent complication during induction treatment. Furthermore, high WBC count (P <.01), intensive chemotherapy (P <.01), malnutrition (P =.007), lack of response to induction chemotherapy (P =.001), delayed presentation (P =.004), and steroid use prior to chemotherapy (P =.023) were all linked with worse OS.

Delayed presentation, furthermore, appeared to be the strongest predictor of worse survival on multivariate analysis with a hazard ratio for OS of 2.51 (95% CI, 1.38-4.55) for patients who had a delay of more than 6 months.

With a median follow-up of 54.64 months, the 5-year OS rate was 69.9%; the 5-year disease-free survival rate was 67.8%. “An early referral will improve the outcome of ALL in children,” the authors noted in their report.


Ahmad I, Ghafoor T, Ullah A, et al. Pediatric acute lymphoblastic leukemia: clinical characteristics, treatment outcomes, and prognostic factors: 10 years’ experience from a low- and middle-income country. JCO Glob Oncol. 2023;9:e2200288. doi:10.1200/GO.22.00288