The Long-Lerm Follow-Up of Childhood Acute Lymphoblastic Leukemia Treated in China with Chemotherapy under Poor Coverage of Medical Insurance: A Single Center Experience.
Authors: Tang Yongmin , Song Hua , Shi Shuwen , Yang Shilong , Wei Jian , Xu Weiqun , Pan Binhua , Chen Yinghu , Zhang Lingyan , Zhao Fenying , Ning Botao , Xu Xiaojun 
Published: October 2019

Abstract
Objectives to report the long-term outcome of childhood acute lymphoblastic leukemia (ALL) treated in our department between 1994 and 2004 under the poor coverage of medical insurance. Subjects and Methods A total of 151 pediatric patients aged 1.1 – 16.2 yrs with a median of 6 yrs were enrolled into this study. Gender: 93 males and 58 females with M:F ratio of 1.6:1. Patients were diagnosed based the morphology, immunophenotyping, cytogenetics and molecular biology markers and divided into standard risk (SR) group (104 cases) and high risk (HR) group (47 cases). Chemotherapy protocols consisted of VDLD (VCR 1.5mg/M2 qw on day 1, 8, 15, 22 + DNR 35mg/M2 qd on day 1, 2 (SR) or on day 1, 2, 3 (HR) + L-Asparaginase (6000U/M2 qod for 10 doses started on day 8 + Dexamethason 6mg/M2 orally for 28 days started on day1 with one week of tapering) for 4 weeks of induction followed by one week of CAT (CTX 800mg/M2 on day1 + Ara-C 50mg/M2 q12h on day1 ~ day7 for SR group or 1g/M2 q12h on day1 ~ day3 for HR group + 6-mercaptopurine 75mg/M2 qn on day1~day7) for consolidation. Then 3 courses of high-dose Methotrexate (HD-MTX) 3g/M2 for SR group or 5g/M2 for HR group for extramedullary leukemia prophylaxis were conducted followed by 3 successive courses of VM-26 150mg/M2 + Ara-C 300mg/M2 every two days for early intensification. In addition to HD-MTX, MTX+Ara-C+Dex in triplicate by intratheacal injection was also performed once a week during induction, consolidation and early/late intensification. Then, 2 weeks of VDLD for late intensification with 2–3 courses of HD-MTX and VM26 + Ara-C intensification with 2–3 courses of HD-MTX were alternated every 6 months until a total of 3 yrs for girls or 3.5 yrs for boys were reached. A total of 7~9 and 9~11 courses of HD-MTX were administered for patients with SR and HR groups, respectively for the extramedullary leukemia prevention. No cranial irradiation was used for the prevention of CNS leukemia. The maximum dosage of DNR was limited to 360 mg/M2. Results. All but two patients got complete remission (149/151, 98.68%) after 4 weeks of induction. The overall 5 yrs of event free survival (EFS) for both SR and HR groups was 70.60% with 85.65% for SR group and 61.36% for HR group. The overall relapse rate was 7/151 (4.63%) cases, of which CNS leukemia 2/151(1.32%) were identified. 3 patients went into second remission with a short duration and relapsed again and died shortly. No testicular leukemia relapse was identified. One patient (1/151, 0.66%) was found to have a secondary leukemia. Of all this patients, 58 patients (38.4%) had one year of medical insurance for a total of 80,000 yuan in RMB (about US$10,000) while 93 patients (61.6%) were all on their own finance. An average of 200,000 yuan in RMB (about US$20,000) was spent for each patient during the whole process of treatment. Conclusions Childhood ALL is curable disease even in patients with poor medical insurance and less intensive as compared to Western countries. The results are comparable to those reported in Western countries.