Thanks to significant improvements diagnostic and treatment strategies in recent decades, the 5-year overall survival (OS) rate for children with acute lymphoblastic leukemia (ALL) is now approximately 90% in high-income countries (HICs).1

In low- and middle-income countries (LMICs), however, the relative lag in technological advances and the dearth of specialty care access has widened disparities in ALL outcomes. In Mexico, for example, the 5-year OS rate among children with ALL is roughly 50%, underscoring the critical need to improve treatment access and quality for this population.1

LMIC-HIC Partnership Improves ALL Outcomes

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In a study published in June 2023 in JCO Global Oncology, researchers implemented and tested a “twinning” program aimed at improving pediatric ALL outcomes through collaboration between 2 hospitals near the US-Mexico border: Hospital General-Tijuana (HGT) and Rady Children’s Hospital (RCH) San Diego, in partnership with St Jude Children’s Research Hospital.2

The collaboration between the 2 hospitals was based on the WHO Framework for Action, a model designed to strengthen health systems and outcomes via 6 interdependent building blocks: health service delivery, health workforce, health information systems, access to essential medicines and technologies, health financing, and leadership and governance.3

The broader potential for this type of approach is the development of sustainable programs to improve cancer outcomes in other parts of Mexico as well as other LMICs, through similar partnerships with centers in HICs.2

Following prospective evaluation of ALL patients and outcomes at HGT from 2008-2012, investigators implemented the program in 2013 and evaluated outcomes through the end of the post-implementation period in 2017. The participant sample included 109 children with newly diagnosed ALL, with 49 children in the pre-implementation cohort and 60 in the post-implementation cohort.2

Compared to the pre-implementation period, the results revealed a post-implementation increase in the 5-year OS in all patient groups: Rates increased from 59% to 65% (P =.023) among the entire cohort, from 73% to 100% (P <.001) among children with standard-risk disease, and from 48% to 55% (P =.031) among those with high-risk disease by the end of the study.2

In addition, all 10 indicators of sustainability assessed in the study — such as effectiveness of the health system to monitor progress, leadership engagement, and infrastructure for sustainability — showed improvement in the post-implementation period.2

Benefits and Limitations

In an interview with Hematology Advisor, oncologist Julie R. Gralow, MD, FACP, FASCO, the chief medical officer and executive vice president of the American Society of Clinical Oncologists (ASCO), noted the previously demonstrated success of the “twinning approach” between LMICs and HICs in supporting the delivery of cancer care and described specific strengths of the collaboration between HGT and RCH.

The project “included many stakeholders and focused on training and capacity building in pediatric hematology/oncology, pediatrics, and nursing, as well as strengthening supportive services in pathology, with the Mexican government agreeing to supply the chemotherapy drugs,” she said. “A particular strength of the program is the partnership with a local non-governmental organization which supported the project with food and lodging and some additional medication coverage.”

Although the cost of medications was split 80/20 between the government insurance program and local foundations, the grassroots organization (Patronato) agreed to cover excess medication expenses in the setting of local or national drug shortages.2

“The demonstrated dramatic increase in survival for children with leukemia within only a decade after implementation of our program validates the use of health systems strengthening models, as they are not only efficacious in improving clinical outcomes but also serve as financial and organizational means of building sustainable capacity,” explained lead author Paula Aristizabal, MD, MAS, a hematologist-oncologist at Rady Children’s Hospital-San Diego and associate professor of pediatrics in the division of pediatric hematology/oncology at UC San Diego in California.

“This partnership has engendered an open and bilateral exchange of resources, expertise, and cross-border access, and the healthcare team and patients at Rady Children’s Hospital benefited significantly from this partnership,” she told Hematology Advisor. For example, RCH adopted culturally appropriate strategies from HGT that could help to improve treatment compliance at RCH, specifically for Hispanic patients. Additionally, RCH physicians have become “more cognizant of resource conservation, since medications and personnel are often perceived as ‘unlimited’ in the US, and these resources can be scarce in LMICs.”

Among the limitations of the model used in the study, Dr Aristizabal pointed to the relatively small scale as well as the close geographical distance (24 miles) between the 2 hospitals, allowing for frequent in-person collaboration that is likely not possible in many other global health partnerships.

Next Steps

Systematic expansion of the twinning approach to other areas of need will require collaboration between a wide range of stakeholders, according to Dr Gralow. Among such efforts, “St Jude, along with the WHO, has embarked on an ambitious Global Platform for Access to Childhood Cancer Medicines,” she said. The initiative aims to provide uninterrupted access to high-quality essential cancer medicines for pediatric oncology patients in LMICs.

“In adult cancer, the Union for International Cancer Control (UICC) is leading the Access to Oncology Medicines (ATOM) Coalition,” Dr Gralow added. ATOM aims to develop solutions to help increase access to essential cancer medicines in LMICs. As a coalition partner, ASCO provides education, capacity building, quality care evaluation, and monitoring support for ATOM.

“It takes a village at both sides of the border to improve access to care and clinical outcomes for underserved children with cancer,” Dr Aristizabal stated. “In sum, sustained improvements in cancer outcomes in LMICs are feasible with innovative cross-border programs, particularly near borders that are shared between a high-income country and a low-income country.”


  1. Castro-Ríos A, Reyes-Morales H, Pelcastre-Villafuerte BE, Rendón-Macías ME, Fajardo-Gutiérrez A. Socioeconomic inequalities in survival of children with acute lymphoblastic leukemia insured by social security in Mexico: a study of the 2007-2009 cohorts. Int J Equity Health. 2019;18(1):40. doi:10.1186/s12939-019-0940-3
  2. Aristizabal P, Rivera-Gomez R, Chang A, et al. Childhood leukemia survival in the US-Mexico border: Building sustainable leukemia care using health systems strengthening models. JCO Glob Oncol. 2023 Jun;9:e2300123. doi:10.1200/GO.23.00123
  3. World Health Organization. Everybody’s business – Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva; 2007.
  4. St Jude Global. Global platform for access to childhood cancer medicines. Accessed July 28, 2023.
  5. Access to Oncology Medicinces Coalition. ATOM Coalition Home. Accessed July 28, 2023.